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PRACTICAL OBSERVATIONS 



ETIOLOGY, PATHOLOGY, DIAGNOSIS, 
AND TREATMENT 



ANAL FISSURE. 



BY 

WILLIAM BODENHAMER, A.M., M.D., 

PROFESSOR OF THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM, ANUS, AND 

GENITO-URINARY ORGANS. 



" Truth is not the child of authority, but of time ; and were we to allow ourselves to suppose, that 
nothing more, or new, could be taught, it is pretty clear that nothing more, or new, would be learnt." 
—Lord Bacon. 

" Nunquam aliud natura, aliud sapientia dicit." — Juvenal. 



ILLUSTRATED BY NUMEROUS CASES AND DRAWINGS. 




NEW YORK r 

WILLIAM WOOD & CO., 61 WALKER STREET. 

1868. 
O 



w* 






Entered according to Act of Congress, in the year 1868, by 

WILLIAM WOOD & CO., 

In the Clerk's Office of the District Court of the United States for the Southern District ol 

New York. 



The New York Printing Company, 

81, 83, and 85 Centre St., 

New York. 



PREFACE, 



The exquisitely painful affection termed fissure of the anus, notwith- 
standing the labors of some of the most eminent surgical authors, is yet by 
no means well understood by the profession. The diagnosis, as well as the 
treatment of it, is far from being established upon a solid basis. There is 
as yet no agreement even, among surgical writers, as to the precise applica- 
tion of the term fissure of the anus, and there still exists a great diversity 
of opinion as to the best method of cure. The author is therefore of opin- 
ion that there is much still to be learned in relation to this disease, and that 
it requires more careful research for its further elucidation. A more 
thorough and critical investigation of the subject would now seem to be the 
more especially necessary, since some of the authorities in treating it, have 
completely mixed up and confounded disease, cause and effect, thereby 
occasioning much obscurity and confusion, which prove a formidable obstacle 
to a correct understanding of the true nature, cause, and treatment of this 
distressing malady. The erroneous and conflicting opinions of these authors, 
however, might be passed by without note or comment, as harmless, did 
they not lead to a treatment not only wrong in principle, but most mis- 
chievous in practice. The author's object, therefore, in this work will be 
principally confined to the consideration of the disease to which the term 
fissura ani really, truly, and legitimately belongs ; and by so doing endea- 
vor to remove some of the obscurities, the difficulties, and the confusion 
which surround it. 

Besides these several considerations, which led the author more immedi- 
ately to call the attention of the profession to the subject of this affection, there 
are others equally weighty. There is no complete and systematic treatise 
on the subject, and the disease is of exceedingly practical importance, in 
consequence of the great suffering to which it gives rise, and its frequent 
occurrence in our own country, and from the fact of its being not unfre- 
quently overlooked, or confounded with some other disease. It is also 
highly interesting from the circumstance that it admits, if well understood 
and judiciously treated, of speedy and complete relief without resorting to 



IV PREFACE. 

the grave operation of M. Boyer, or any other serious or formidable 
measure. Whilst on the other hand, when not well understood, it is 
liable through misdirected measures to be seriously aggravated. Great good 
may be done by one well acquainted with the disease, while much harm by 
one who treats it ignorantly. 

Anal fissure is by no means uncommon in this country, although some 
eminent authors are of opinion that the disease, as described by M. Boyer, 
is extremely rare, being scarcely ever observed by American practitioners. 
The able and highly accomplished medical writer, Dr. Reynell Coates, of 
Philadelphia, who is the author of the most able production on anal fissure 
in this country, remarked in 1841, that — "We have never met with it, 
either in public or in private practice, and several eminent surgeons in 
Philadelphia declare that it has not occurred under their observation." 
(American Cyclopaedia of Practical Medicine and Surgery. Vol. II. p. 
118. Philadelphia, 1841.) That this disease is not rare or uncommon in 
this country, the author himself has had ample opportunities of verifying, 
during a practice of thirty years in the cities of New Orleans, La., Louis 
ville, Ky., and New York ; having within this period treated, he is sure, 
more than a thousand cases. This, it seems to him, must be the experience 
of every surgeon of extensive practice, especially of those in our large cities. 

So far as the author's treatment of this disease is concerned, he has nothing 
new to offer in this work. He has no novel method to recommend, which, 
by some species of coup de main practice, would hold out to both the sur- 
geon and the patient an instantaneous or miraculous cure, by which to 
excite the enthusiasm of the former and the hopes of the latter. He has 
only recommended a steady and a skilful perseverance in carrying out the 
practice of well known, long tried, and safe measures to a successful issue ; — 
hence he is aware that his treatment will be unattractive to those purely 
surgical enthusiasts who delight more in obtaining their ends by a prompt 
recourse to the knife, or to manual force, than by the milder, safer, and 
surer measures offered in the judicious practice of a long tried, less ostenta- 
tious, though much more solid and conservative method of cure. 

In this work, besides the method especially adopted and recommended 
by the author, he has, as far as his knowledge extends, fully given all other 
methods, from the earliest times, with all the improvements, down to the 
present ; and, for the benefit of the student as well as the practitioner, this 
has been done in as succinct, as practical, and as accessible a form as possible, 
or as the nature of the case would admit. 

It may be alleged by the learned and the experienced that, in treating 
such an apparently simple subject as anal fissure, the author has been too 
prolix, too diffuse ; but let it be remembered that he has not written entirely 



PREFACE. V 

nor even principally for these. " Doctis indoctisque scribimus" It is the 
great aim of the author to make that which is true, rather than that which 
is new, more generally known through all the ranks of the profession. 

Should this work, as the author humbly trusts it may, aid in clearing the 
diagnosis of anal fissure and spasmodic contraction of the sphinctores ani ; 
or in removing some of the obscurities, perplexities, and doubts to a clear 
understanding of the true character and treatment of fissure of the anus, 
he will feel amply rewarded for his labor. But, whether this expectation is 
realized or not, he has at least endeavored, to the best of his ability, to 
accomplish all that an individual under such circumstances could hope to 
effect, by candidly and fully submitting to the profession everything on this 
subject which a considerable experience, both in reading and in practice, has 
instructed him. 

In conclusion, the author would observe that he has illustrated this work 
by a number of diversified cases, some of which he treated many years ago, 
and by numerous drawings. The instruments represented by some of these 
were manufactured at the old established house of Messrs. George Tiemann 
& Co., No. 6j Chatham Street, New York. The intelligence and the in- 
genuity of the members of this firm, as surgeons' artists, the author has had, 
for a number of years, the most ample opportunities of witnessing. 

New York, October,. 1868. 



TABLE OF CONTENTS. 



CHAPTER I. 

INTRODUCTION. 

Section I. 

History. — Progress, the all-absorbing and controlling idea of the age. The 
science of medicine no exception to this all-prevailing principle : its upward and 
onward tendency evident. The ignorance heretofore on the subject of the diseases 
of the anus and the rectum. The failure to make a proper exploration of the rectum 
one of the causes of this ignorance. Since the introduction of anaesthetics, the 
surgery of the rectum, especially its manipulative branch, has made rapid progress. 
These, and the now common use of the speculum ani and the rectal endoscope, are 
daily revealing the dark and hidden mysteries of this darksome passage. Fissure of 
the anus received but little attention previous to the time of MM. Boyer, Beclard, 
Dupuytren, Blandin, and a few others. About fifty years ago, M. Boyer called 
especial attention to the subject of this disease, from having treated a large number 
suffering from it in its most aggravated form. He was of opinion that the disease 
called fissure of the anus, by the ancients as well as by the moderns, was not identi- 
cal with that which had come under his own observation ; and that previous to his 
time this disease was never observed with attention, neither was it accurately 
described nor correctly treated by any one. From this sweeping declaration the 
author dissents in toto. A comparison between the fissura ani of the ancients and 
that described by M. Boyer. The former believed it to be simply what its name 
imports, a superficial breach of surface of the mucous membrane, of a peculiar form ; 
the latter believed anal fissure to be always accompanied by a painful spasmodic con- 
traction of the sphincter ani muscle, and that this painful contraction indeed consti- 
tuted the real disease, whether attended by any breach of surface or not ; the former, 
that it was an idiopathic disease of the mucous membrane ; the latter, that it was an 
idiopathic disease of the sphincter ani muscle itself. The ancients, when speaking 
of fissura ani, do not mention anal spasm. What Paulus /Egineta, Albucasis and 
iEtius say on the subject of fissura ani. The chief indication in the treatment of 
this disease by the ancients was to convert the original fissure or ulcer into a recent 
wound by scarification and by topical medication. It is worthy of remark, that a 
fresh wound made in the mucous membrane, or in the irritable fissure of the same, 
is not attended with the same severe suffering, after the act of defecation, that arises 
from the original fissure or idiopathic disease ; that such a wound produces at first 
nothing but a common soreness, but at the same time tends to relieve the pain and 
cure the disease. The ancients then, to cure this disease, converted the primitive or 
original lesion into a recent or fresh one, and thus ultimately healed it. What have 



Vlii TABLE OF CONTENTS. 

the moderns now any better than this ? Even if the fissure is attended by anal spasm, 
all that is necessary, as a general rule, to effect a radical cure is to heal the fissure, 
and the anal spasm will cease of itself. From what M. Boyer says, he doubtless 
believed that he himself was the first to make the discovery that anal spasm always 
accompanied anal fissure, and that it was its characteristic or pathognomonic sign ; 
indeed, all his admirers attribute to him the origination of this idea. In this, how- 
ever, both he and they are mistaken, for nearly three hundred years before he or 
they promulgated this idea, the celebrated French surgeon, Ambrose Pare, accu- 
rately described the disease called fissure of the anus, as consisting of cleft and very 
long little ulcers, situated in the orifice and the canal of the anus, and attended by 
very sharp and burning pain, and by great contraction and narrowing of the anus. 
The description and the treatment of fissure of the anus given by M. Pare. The con- 
sideration of the theory of those of the moderns who teach that anal spasm is in 
reality the idiopathic disease, of which the breach of surface or fissure, if any, is but 
an accidental accompaniment or consequence. The views on this subject of each of 
the following eminent surgeons who held this doctrine, — MM. Boyer, Dupuytren, 
and Sir Benjamin Brodie. The declarations of these gentlemen, however, on this 
subject have never been verified by any satisfactory ante- ox post-mortem examination, 
and rest merely upon assertion. The views of MM. Blandin, Sanson, Quain, and 
Bushe in opposition to this theory. The views of M. Velpeau in conciliation of these 
conflicting theories. . Pages 3-21 

Section II. 

Spasmodic Contraction of the Anus. — Nervous irritation in muscular parts 
often occasions partial and sometimes obstinate contractions. "When this occurs in 
the anal canal it constitutes what is generally called spasmodic contraction of the 
anus. There are three kinds of muscular contraction — the spasmodic, the perma- 
nent or organic, and the mixed, which partakes of the characters of both. The first 
can always be dilated to the full size of the canal in which it exists, and of which 
nothing can be learned by dissection after death, because the spasm depends upon a 
living and active principle which ceases with life. The second and third can not 
only be detected in life, but can be demonstrated post-mortem. How a spasmodic 
contraction may become permanent or fixed. Anal spasm as an entity a disease in 
itself. The independent existence of anal spasm is a theory held by some of the most 
able surgical writers on the diseases of the rectum and anus ; but as the principles 
of it rest purely upon the evidence of facts, fairly and fully ascertained and set forth, 
they fail, in the opinion of the author, to establish it. The author shows that the 
numerous cases which these writers have presented to illustrate this theory are, in 
reality, cases of anal fissure, or of some other disease of the mucous membrane of 
the inferior extremity of the rectum ; or of disease in the genito-urinary organs, and 
not cases of primary or independent disease of the sphincter ani muscle itself. The 
following are the authors quoted in this work who have treated anal spasm as an 
entity, a disease in itself, and who have made it a subject of special consideration : — 
M. Boyer, Mr. Copeland, Mr. Baillie, Mr. Gaitskell, Mr. Blackett, Mr. White, Mr. 
Howship, Mr. Calvert, Mr. Mayo, M. Chelius, Mr. Salmon, Dr. Bushe, Mr. Curling, 
and Mr. Malyn. The views and the cases of each of these authors given, with com- 
ments upon the same 21-40 



TABLE OF CONTENTS. IX 



CHAPTER II. 

FISSURE OF THE ANUS. 

Section I. 

Name. — The disagreement among authors as to the precise application of the term 
fissure of the amis. It is incorrectly applied by some to anal spasm, a mere symptom 
of anal fissure, and by others equally incorrect to every superficial lesion of what- 
ever character, situated in the inferior extremity of the rectum, and about the margin 
of the anal orflce. The term fissure of the anus in its limited sense, or in its strict 
application. The term as used in its more extended sense. The difference in the 
form of these superficial lesions of the inferior extremity of the rectum and about 
the anal orifice. Their characteristic form is doubtless imparted to them by the 
irregularities of the mucous lining of the rectum, disposed as it is into numerous 
rugae. This term not a good one to designate this painful affection, inasmuch as 
the mere form of the lesion, whether linear, circular, or oblong, is not the char- 
acteristic sign, neither does it determine the true nature of the disease. Its use, 
however, has been so long sanctioned by authority that the author does not feel at 
liberty to venture upon the substitution of a newly created one. The term thus 
retained by the author as a nosological distinction, he strictly confines to superficial 
breaches of surface in the anal region of a highly sensitive, irritable, or painful char- 
acter, whether linear, oblong, or circular ; or whether' attended by anal spasm or not. 
Mr. Curling very appi"opriately denominates fissure of the anus, " irritable ulcer of the 
rectum" He, together with Mr. Quain and Mr. Smith, of London, repudiates the 
term, fissure of the anus Pages 43-46 

Section II. 

Physiology. — A brief description of anal fissure given as preliminary to the sub- 
ject of physiology. It is an idiopathic disease of the mucous membrane of the infe- 
rior portion of the rectum ; or of the muco-cutaneous coat about the anal orifice, and 
not a disease of the muscular coat, or muscular fibres of the intestine, nor of the 
sphincters of the anus. The excessively irritable and excitable fissure of the mucous 
membrane communicates its irritability and excitability to the muscular coat and 
to the sphinctores ani muscles, and causes one or both of them to contract violently. 
The sphincter ani muscles are sympathetically impressed or influenced by the morbid 
condition of the fissure — hence the spasm. In some morbid conditions of the anus, 
or anal region, whether induced by fissure or by some other cause, extreme sensi- 
bility of the nerves of the part and spasmodic contraction of the anus coexist as parts 
of the same disease. Sensibility of the terminal outlets of the body. The sensibility 
of all mucous membranes is greatest at the extremities, or the outlets of the canals 
which they line. The outlets of the body are supplied or endowed with a peculiar 
nervous influence which is obviously connected with their proper function. The 
direct cause of the extreme and agonizing pain in anal fissure is the result, to a 
great extent, of the violent involuntary spasmodic contraction of the sphincters of the 
anus upon the already highly sensitive and painful ulcer. This view of the subject 
is in accordance with the pathology of the disease, as well as with the physiological 
condition of both sphincters of the anus, whose involuntary contraction, both tonic 



X TABLE OF CONTENTS. 

and spasmodic, is entirely owing to a peculiar nervous endowment. The tonic and 
the. muscular contraction of the anal sphincters. The explanation of each. The 
influence of the will upon the anal sphincters. These two muscles stand in physio- 
logical function between the involuntary and voluntary system of nerves. The sup- 
position that a special nervous influence is necessary to govern the relaxation and 
the contraction of the anus has be*en entertained by several eminent physiologists. 
The views of the ingenious and talented Italian, Professor Bellingeri, on this subject. 
The fibres of the anal sphincters may be stimulated to action directly by the will, or 
indirectly by reflex irritation, the one action being voluntary and the other involun- 
tary. The philosophy of reflex action in its relations to nervous phenomena is at 
the present time attracting great attention. To know that all morbid manifestations 
may be due to reflex influence is of the highest importance. The nervous endowment 
of the rectum. Hypertrophy of the external sphincter of the anus. . Pages 47-53 



CHAPTER III. 

ETIOLOGY. 

Constipation of the Bowels as a Cause of Anal Fissure. — The ancients 
attributed fissure of the anus principally to constipation of the bowels, and to the 
desiccated condition of the stercoraceous matters incident to such a constipated state. 
It is obvious how constipation with all its train of evils, retention and induration of 
the faeces, and the violent action of the expulsive muscles requisite for their evacua- 
tion, may be a cause of anal fissure. Anal fissure is sometimes the result of inflam- 
mation, and the attendant turgescence of the mucous membrane of the anal canal. 
It also sometimes results from the excoriations produced by the vitiated and irrita- 
ting discharges in dysentery, diarrhoea, cholera, and other visceral diseases. Obstinate 
ulcers or fissures are sometimes produced in the fossa between the two anal sphinc- 
ters, by the continued lodgment in this situation of faecal matter or other foreign 
bodies. Severe straining efforts a cause of anal fissure. A somewhat frequent cause 
is a deficiency in the secretion of the natural lubricants — the mucous and other secre- 
tions of the inferior extremity of the rectum and about the anal orifice. Anal fissure 
from mechanical injuries, such as the lacerations which are produced by over disten- 
tion, by the passage of hard fasces, as well as those which sometimes follow surgical 
operations, and the careless and awkward use of the pipe of the enema syringe, the 
speculum ani, the rectal sound or bougie. It is sometimes the result of external vio- 
lence communicated by falls, blows, etc., upon the anus, the nates, or the coccyx. 
Anal contraction as a cause of anal fissure. Anal fissure from the frequent use of 
enemata. Anal fissure from cutaneous affections. The venereal origin of anal fissure. 
Can anal fissure be produced artificially ? Are the causes of anal fissure obscure ? 
Who are the most obnoxious to anal fissure ? 57—67 



CHAPTER IV. 

CLASSIFICATION AND DESCRIPTION OF ANAL FISSURE. 

Section I. 

The Seat, the Anatomical and the Pathological Characters of Anal 
Fissure. — The importance of distinguishing and describing fissures of the anus in 



TABLE OF CONTENTS. XI 

accordance with their location. Some authors think such distinction of no therapeu- 
tical value. The great difference in the appearance of the fissure or ulcer, arising 
from its location. MM. Blandin and Dupuytren acknowledge the importance of 
such distinction. M. Blandin divides anal fissures into three divisions. The author 
distinguishes them into four classes, according to their locality, describing the pecu- 
liar character they assume in each of such position. A description of the seat, the 
anatomical and the pathological character of each class. . . . Pages 71-78 

Section II. 

The Symptoms and the Signs of Anal Fissure. — The most striking feature 
in the nature of anal fissure is the great disproportion which exists between the extent 
of the solution of continuity, and the intense suffering it occasions. The character- 
istic or essential symptoms of anal fissure. The interval of time and its length 
between the act of defecation and the accession of the pain, as a pathognomonic sign 
of anal fissure. What Mr. Colles and Mr. Quain say on the subject of this phenom- 
enon. The explanation given of it by Prof. Van Buren and Mr. Malyn. Symptoms 
and signs of anal fissure in infants. They differ essentially from those manifested in 
the adult. The difference pointed out 79~9° 

Section III. 

Physical Exploration, Diagnosis, and Prognosis. — The measures necessary 
to be observed previous to making a thorough inspection of the rectum. The posi- 
tion of the patient and the manner of making the exploration. The external appear- 
ance of the anus in anal fissure. It is almost always strikingly retracted. The 
condyloma or pendulous projection, composed of the integument at the margin of 
the anus, and located at the base or inferior extremity of the fissure. It exists in 
most all cases, and is an unerring guide to the fissure itself. The digital exami- 
nation of the anal canal and the preparatory measures necessary for it. The 
specular examination of the inferior extremity of the rectum and the preparatory 
steps necessary to it. Description of three anal speculae used by the author. The 
examination by means of the probe. The diagnosis. The prognosis. The com- 
plications of anal fissure. . 90-103 



CHAPTER V. 

THE TREATMENT. 

Section I. 

Precautionary and Palliative Measures. — It is highly important to the suc- 
cess of any treatment of fissure of the anus that constipation of the bowels, if it exists, 
should be corrected, by securing their daily evacuation, and thereby preventing faecal 
accumulation. It is also a primary object to prevent the formation of acrimonious 
matter in the bowels, and to take especial care to preserve an easy and regular trans- 
mission of their contents, which for this purpose should as much as possible be kept 
in a semi-fluid state, as figured or hard stools generally aggravate the symptoms. 



Xll TABLE OF CONTENTS. 

These several ends must be effected by enjoining the most bland and unirritating diet ; 
and by the use of emollient enemata, or mild aperients. The measures recommended 
by the author to accomplish the certain evacuation of the bowels daily, and the easy - 
transmission of their contents. The following as palliatives to be used sometimes in 
certain cases and under certain circumstances — leeching, fomentation, horizontal 
posture, cold applications, and local anaesthesia. The palliative measure of M. 
Gossement Pages 107-109 

Section II. 

The Treatment as Pursued by the Author. — It consists of topical medi- 
cation combined with dilatation and sometimes scarification or incision of the mucous 
membrane. The chief indication is to modify the surface of the ulcer and transform 
it into a simple or a common sore. Distention of the spasmed anal sphincters ; its 
object, and the method of accomplishing it. The author's method of treating anal 
fissure in infants. 110-119 

Section III. 

The Different Methods of Treatment. — These may be included under the 
following heads : — 1. Topical Applications ; — 2. Cauterization ; — 3. Dilatation ; — 
4. Incision of the Mucous Membrane ; — 5. Excision of the Fissure ; — 6. Complete Divi- 
sion of the Sphincters of the Anus. The treatment by topical applications. It is 
said by some to be merely palliative, and by others to be impracticable, or positively 
injurious. The author proves by the highest authority, that it has not only been 
found practicable, but that it has been attended with the most complete success in 
numerous instances. The numerous and various topical applications given, together 
with the names of those who employed them, and the success or failure attending 
their application. 2. The treatment by cauterization. The indication contemplated 
by the use of the cautery, either in its potential or in its actual form. The potential 
cautery employed in the treatment of fissura ani from the earliest times. The dif- 
ferent kind of caustics, with their mode of application. M. Jules Guerin recommends 
the actual cautery. Objections to this remedy. 3. The treatment by dilatation. 
The object and the method of employing it in anal spasm when caused by fissure of 
the anus. Dilatation by the use of the bougie. It was employed and recommended 
by Mr. Copeland, Mr. Gaitskell, and Mr. Howship as early as 1815. The principle 
of muscular distention and dilatation as recommended and so successfully employed 
by M. Recamier. Dilatation by the use of different kinds of tents. Forcible and 
instantaneous dilatation of the sphincters of the anus by means of the fist, was first 
executed and recommended by M. Maisonneuve. This operation met with no favor. 
A modification of this operation was subsequently made, by substituting the thumbs 
for the fist. The manner of performing it as practised by M. Nelaton, who is its 
advocate. This method of dilatation of the anal sphincter in fissure of the anus and 
some other diseases of these parts is adopted and recommended by Professor Van 
Buren. The objections. A modification of it recommended by the author, in which 
the index fingers are used instead of the thumbs. 4. The treatment by incision of 
the mucous membrane. Mr. Copeland the first who recommended it as a substitute 
for M. Boyer's operation. What Sir Benjamin Brodie and Mr. Quain say on this 
subject. Mr. Curling and Mr. Smith are of opinion, that besides the division of the 
mucous membrane and submucous cellular tissue, it is necessary to the success 



TABLE OF CONTENTS. Xlll 

of the operation that some of the muscular fibres should be divided. The author 
differs from this opinion. The modus operandi of this operation. The author's 
method of performing it by a new instrument. 5. The treatment by excision of the 
fissure. This operation, the author believes, was first proposed and executed by M. 
Velpeau. In it the integrity of the muscular coat is preserved, neither the muscle 
nor the muscular fibres of it being interfered with. The modus operandi. 6. The 
treatment by complete division of the anal sphincters. The merit of first executing 
and recommending this operation in case of anal fissure, is universally attributed to 
M. Boyer. The objections to this operation. It is founded upon a mere hypothesis. 
The anal spasm for which the operation is advised is only a symptom, an effect, or a 
result of the fissure, which is in reality the real disease. The operation is wrong in 
principle and mischievous in practice, and cannot be approved of, upon rational 
grounds. All treatment is irrational that is not immediately directed to the morbid 
condition of the mucous membrane of the part, or that does not immediately tend to 
heal the fissure itself, which is the real disease. The operation was considered to 
be infallible by M. Boyer ; it is, however, proved by MM. Recamier, Beclard, 
Velpeau, and others, not to be so. The accidents and the dangers of the operation. 
The manner of performing it as advised by M. Boyer. A modification of M. Boyer's 
operation by M. Blandin. It consists of the submucous and subcutaneous section of 
the sphincter ani muscle. It is ingenious, simple, far less formidable and repulsive, 
equally successful, and attended with much less risk. A description of the instru- 
ment, and the manner of performing the operation. The proceeding of M. Boyer as 
modified by the late and lamented Dr. Hayward, of Boston. It consists of the divi- 
sion of the sphincter ani from without inwards, instead of from within outwards, as in 
the operation for complete fistula in ano. The manner of performing the opera- 
tion. Pages 1 19-147 



CHAPTER VI. 

CONCLUSION. 

Section I. 

Illustrative Cases. — Case I. Anal fissure of nine months' standing, caused by 
obstinate constipation of the bowels, and the continued use of drastic purgatives. 
Case II. Anal fissure complicated with haemorrhoids. Case III. Anal fissure com- 
plicated with a small blind internal fistula — the patient having been treated several 
months for internal irritable piles. Case IV. Anal fissure of an aggravated char- 
acter, in which the sphincters of the anus had been divided with the knife. Case V. 
Anal fissure in a little boy three years old, caused by obstinate constipation of the 
bowels, the result of inactivity of the liver induced by intermittent fever. Case VI. 
Anal fissure complicated with fistula in ano, spermatorrhoea, and ascarides of the rec- 
tum. Case VII. Anal fissure complicated with a blind internal fistula. Case VIII. 
Highly irritable ulcer, situated in the fossa between the external and internal sphinc- 
ter of the anus. Case IX. Irritable ulcer of the rectum simulating uterine disease, 
and a large accumulation of hard and impacted faeces in the left colon simulating a 
tumor in that region. Case X. Anal fissure in an infant ten months old. Dentition, 



XIV TABLE OF CONTENTS. 

persistent diarrhoea, and procidentia ani. Case XI. Anal fissure, previously diag- 
nosed and treated by different physicians, severally as neuralgia of the inferior 
extremity of the rectum, internal piles, and constipation. Case XII. Anal fissure 
attended by great flatulency, and accompanied alternately by constipation and diar- 
rhoea. The true nature of the case having been overlooked, it was treated severally 
as dyspepsia, anal neuralgia, and internal piles. Case XIII. Anal fissure compli- 
cated with haemorrhoids. In this case the fissure, having been entirely overlooked 
by the previous medical attendants, was diagnosed and treated by them as irritable 
piles. Case XIV. Anal fissure complicated with haemorrhoids and with spermator- 
rhoea. Case XV. Anal fissure the result of the application of nitric acid to the mu- 
cous membrane of the anal canal. Case XVI. Anal fissure from a rupture of the 
mucous membrane of the anal canal, the result of a fall upon the nates. Case XVII. 
Several fissures complicated with numerous condylomata and with permanent 
contraction of the anus. Case XVIII. Anal fissure complicated with an intolerable 
pruritus of the anus. Case XIX. Anal fissure in an infant suffering from aphthae. 
Case XX. Anal fissure complicated with haemorrhoids and an affection of the pros- 
tate gland. Case XXI. Anal fissure complicated with haemorrhoids, the fissure 
ocated between two of them. Case XXII. Anal fissure caused by chronic irritation 
of the mucous membrane and muco-cutaneous coat of the anus. Error in diagnosis 
and failure to afford relief by previous treatment. Case XXIII. Anal fissure in a 
nursing mother who was suffering severely from aphthae. Case XXIV. Anal fissure 
complicated with haemorrhoids and with an anal fistula. Case XXV. Fissures and 
aphthous abrasions and ulcerations of the anus in connection with nurses' sore mouth. 
Case XXVI. Anal fissure following the ligation and sloughing of a haemorrhoidal 
tmnor. Case XXVII. Anal fissure in a patient with albuminous urine, whose gen- 
eral health was much impaired. Case XXVIII. Anal fissure the result of obstinate 
constipation of the bowels, and the passage of scybalous faeces. Case XXIX. Ir- 
ritable ulcer, situated in the fossa between the external and internal sphincter of the 
anus Pages 151-192 

Section II. 

Bibliography. 192-199 



CHAPTER FIRST. 



INTRODUCTION. 



PRACTICAL OBSERVATIONS 



ON THE 



ETIOLOGY, PATHOLOGY, DIAGNOSIS, AND TREATMENT 



OF 



ANAL FISSURE. 



CHAPTER I. 

INTRODUCTION. 
Section I. — History. 

Progress, either in remodelling the ancient order of things, 
or in creating a new one, is the one and controlling idea of 
the present age, and no theories that stand in the way can long 
exist. Systems and doctrines, gray with the growth of ages, 
are in a few days overthrown and swept away like cobwebs, 
although crystallized by time, and fortified by the genius and 
labors of a hundred generations. The science of medicine 
is no exception to this all-prevailing principle, as it too is 
now rapidly moving onwards and upwards. There is no 
better evidence of the rapid march of medical science at the 
present time than is found in the increased accuracy of diag- 
nosis, aided by a careful study of the physical signs of 
disease. 

The ignorance on the subject of the diseases of the rec- 
tum which had so long prevailed, and which to a certain 
extent still more or less exists, may very justly be attributed 
to the failure on the part of practitioners generally to make 
a proper exploration of this organ. The rectum heretofore 



ANAL FISSURE. 



has been a terra incognita in the domain of surgery, into 
which the practitioner did not care to pry : it has been con- 
sidered a <fc sort of land of the Cimmerians, where quacks 
alone could breathe, and where humbug darkened the air." 
But this ignorance and this darkness are now being rapidly 
dispelled, and this organ is now becoming as subservient to 
the laws of physical exploration as any other. The surgery 
of the rectum, particularly as it regards its manipulative 
branch, has made rapid strides since the introduction of 
anaesthetics. These, and the now common use of the 
speculum ani and rectal endoscope, are daily revealing the 
dark and hidden mysteries of this darksome passage. 

Anal fissure received but little notice from surgical writers 
previous to the time of MM. Boyer, Dupuytren, Blandin, 
Velpeau, Becklard, and a few others. This neglect or igno- 
rance of the subject, on the part of the ancients, as well as 
on the part of the moderns, was, however, not confined 
alone to the disease in question, but extended to most all 
of the diseases of the rectum and anus. It is therefore 
highly creditable to the pathologists of recent times, that 
they are extending their researches to every form of suf- 
fering incident to these parts, and are laboring assiduously 
in this field which had been so long entirely neglected by 
their predecessors, and when found was nothing but a tabula 
rasa^ but which, as before remarked, is now being cultivated, 
enriched and developed by their conjoint and active labors. 

About half a century ago the celebrated French surgeon 
Baron Boyer directed special attention to the subject of 
this disease, in consequence of having treated a large num- 
ber of adults of both sexes who had suffered from it, in its 
advanced stage or in its most severe form ; indeed all the 
cases that came under the immediate observation of this 
distinguished surgeon at that time seemed to have been of 
a most aggravated character. From the circumstance, doubt- 
less, of the great severity of these cases, and especially of 



ANAL FISSURE. 5 

their having been accompanied by spasmodic contraction 
of the sphincter or sphincters of the anus, he came to the 
conclusion that the disease which he had seen and treated 
as fissure of the anus could not be identical with that so 
denominated by the ancients as well as the moderns, in- 
asmuch as he had consulted their works in vain to find a 
description of it, to accord with the disease as it presented 
itself to him. He says it is true that Albucasis makes 
mention of a disease which he calls fissure of the anus, 
and which he does not describe, but which he recommends 
to be treated by paring or scarifying the fissure with the 
nails or with a sharp instrument, and that by this means 
and the aid of God the disease would be cured. But, says 
Boyer, the affection of which Albucasis speaks cannot be 
similar to that which came under my own observation. 
Boyer also says that M. Sabatier makes mention of anal 
fissure as being a disease consisting of narrow and long 
excoriations about the margin of the anus, and as being an 
affection both painful and difficult to cure, and that it was 
astonishing no author had yet spoken of it, or had given a 
description of it. To which Boyer further remarks, that 
Sabatier was no doubt ignorant of the fact, as he himself 
had been but a short time previous, that M. Lemonnier, 
in a work on fistula of the anus 3 published as long ago as 
1689, describes fissure of the anus as follows: — "Les raga- 
des ou fissures sont de petits ulceres douloureux, piquans et 
sans grosseur, qui suivent la longueur des rides du fonde- 
ment, et qui ressemblent assez a ces engelures ou crevasses, 
que le froid produit aux levres etaux mains pendant l'hiver; 
elles sont quelquefois causees par l'endurcissement des 
matieres fecales, qui, s'etant amassees dans le rectum en 
gros volume, et qui rendues apres par un exces de chaleur, 
par leur dessechement et leur sejour, excorient ou fendent 
le sphincter et l'anus en passant." — (Tratte de la Fistule de 
L'Jnus, p. 160. Paris , 1689.) "Now it is evident," says 



ANAL FISSURE. 



Boyer, " from what M. Lemonnier says, that he understood 
the disease called fissure of the anus. But this malady 
which he describes, is it the same which I myself have 
observed? I do not believe it." M. Boyer did not consider 
that the fissura ani spoken of by Albucasis and other 
ancients, nor that mentioned by Sabatier and so well 
described by Lemonnier, could have been similar to that 
which he himself had observed and treated; because no 
particular mention is made by these authors of the agoniz- 
ing pain and the anal spasm which sometimes accompany 
this disease ; and because the measures they had recom- 
mended and adopted were, as they themselves declare, 
completely successful in curing it; whereas all the patients 
that had come under the immediate care of himself for 
the treatment of anal fissure, had suffered the most exqui- 
site pain, attended by violent spasmodic contraction of the 
sphincter ani, and had previously employed every variety 
of application that could be suggested capable of procuring 
relief without affording the least permanent benefit. In 
another place Boyer again refers to the same subject in the 
following language : — " Tel est le resultat de mes observa- 
tions sur une maladie jusqu'a present meconnue, et contre 
laquelle on a employe des remedes tres-souvent inutiles, 
quelquefois nuisibles, et toujours insuffisants." — (fTraite 
des Maladies Chirurgicales, 'Tome Z 7 /., p. 614. Cinqideme Edit. 
Paris, 1849.) 

From these several premises this celebrated surgeon comes 
to the conclusion that the disease which he denominates 
fissure of the anus, if it was not a recent disease, or un- 
known, was, at least previous to his own time, never 
observed with attention, neither was it accurately described, 
nor correctly treated by any one. Now from this sweeping 
conclusion of M. Boyer, who furnishes no adequate detail 
of the facts upon which his opinions rest, I most respect- 
fully beg leave to dissent in toto, simply because I believe 



ANAL FISSURE. 7 

his premises are not founded in truth. He has done both 
the ancients and the moderns more or less injustice, as I 
shall fully demonstrate before I dismiss the subject. From 
the high position of this author, the extensive circulation 
of his views upon this subject, and the consequent influence 
his opinions must have upon the medical profession, not 
only in his own but in other countries, it becomes a ques- 
tion of no little moment, how far those views are founded 
upon a rigid induction of facts; for without these, theories 
in medicine are at least worthless, if not pernicious in their 
results. The adroit and skilful manner in which M. Boyer 
handles the subject of this disease, and the highly chaste 
and classic language in which he clothes his opinions, are 
so fascinating that his doctrine finds a ready reception in 
the unwary mind. On this account, the very plausible 
theory which he has advanced cannot be examined with 
too much freedom. It is here important to inquire what 
the ancients considered fissure of the anus to be, and to 
compare their description of it with that given it by Boyer 
himself, so as to be able to determine the difference between 
them. I will show that the ancients considered it to be 
precisely what they termed it, or what its name imports — 
a superficial breach of surface simply, of a peculiar form, 
situated within or immediately without the anal orifice, and 
attended with more or less sharp or burning pain. I will 
also show that what M. Boyer considers anal fissure to be is 
altogether a much more complicated affair, and that this 
term, when applied to what he believes this disease in 
reality to be, is a misnomer and has no significance. Pain- 
ful spasmodic contraction of the sphincter ani muscle is 
in reality the anal fissure of M. Boyer ; but it was not the 
fissure of the ancients, for they do not even name spasm 
of the sphincter ani when speaking of anal fissure. They 
doubtless witnessed anal spasm, and when they did so, they 
considered it as an independent, or a separate and distinct 



8 



ANAL FISSURE. 



disease altogether, as I will show some of the moderns 
have since done and continue now to do. Anal spasm 
attended anal fissure in the times of the ancients as it does 
now. The disease has never undergone any change in this 
respect, being precisely the same now as it was then. The 
ancients only erred in not recognizing anal spasm as one of 
the signs of anal fissure, but considered it an entity ; hence 
they failed to this extent in giving it a full description. 
Many of the moderns, however, with all their advantages, 
are no better in this respect, as they have committed and 
continue to commit the same error. I will show, however, 
that M. Boyer can have an anal fissure without any breach 
of surface, without a fissure, for he teaches that the spas- 
modic contraction of the sphincter ani constitutes the 
disease called fissura ani, that it exists as an idiopathic 
affection, whether attended by a fissure or not; and not 
only so, but that the anal spasm is the primary as well as 
the principal morbid condition ; and even that it is one of 
the most remarkable predisposing causes of anal fissure. 
I have thus briefly stated the main points of difference 
between the ancients and M. Boyer on this subject, and it 
will be observed that whilst the former consider the disease 
to consist merely of a superficial idiopathic lesion, attended 
by more or less sharp or burning pain, &c, the latter con- 
siders the disease to consist of a painful spasmodic con- 
traction of the sphincter ani, whether attended by any 
lesion or not, &c. 

I will now proceed to the proof. It will be conceded 
by all who are familiar with the little that is said in the 
writings of the ancients on this subject, that they included 
in the term fissura ani every superficial lesion about the 
anus, or inferior extremity of the rectum, in the form of 
fissure, chap, crack, rhagade, excoriation, abrasion, &c. 
The ancients are silent with regard to the spasmodic con- 
traction of the sphincter ani muscle, a phenomenon which 



ANAL FISSURE. 



sometimes attends anal fissure in its advanced or aggravated 
stage ; but, at best, this spasm of the sphincter is nothing 
but one of the symptoms, effects, or evidences of the fissure, 
and not the disease itself. The rationale of the phenomenon 
is, that the sphincter ani is brought into this exalted action 
solely in consequence of the irritation of the fissure upon 
the mucous membrane within the grasp of the muscle, and 
the influence of reflex nerve action. The ancients, as 
before observed, doubtless witnessed cases in which this 
hyper-action of the sphincter existed, and if they did they 
might naturally enough have come to the erroneous con- 
clusion that it was a disease of the muscle itself, being 
spasmodic in character and separate and distinct in its 
nature ; and this would seem the more especially so, since it 
was extremely difficult then, under the most favorable circum- 
stances, to make such an exploration as would result in the 
detection of a fissure or of any other disease of the anal canal, 
at least whilst the anal spasm lasted. Now if this supposi- 
tion in relation to the ancients be true, then they were to a 
considerable extent excusable for embracing this error, sur- 
rounded as they were by so many unfavorable circumstances 
towards making a proper inspection of the parts. Not so, 
however, those of the present day, with anaesthetics, the 
speculum and endoscope, who hold precisely similar errors 
in relation to spasmodic contraction of the sphincter ani. 

The celebrated Grecian, Paulus iEgineta, in his most 
admirable synopsis of the medical literature of the ancients, 
says, and very correctly too, that, — "Fissures are occasioned 
principally by hard fseces, and being slow of granulating, 
owing to their callosity, must be converted into recent 
ulcers by paring (excoriating, scarifying, or incising) them 
with the nails, or a scalpel; when they may be made to 
granulate by proper applications." — (Libri Septem. Lib. VI., 
cap. 80, English Version, by Adams. Vol. IL, p. 405. London, 
1846). 



10 ANAL FISSURE. 

Albucasis was perhaps the first who recommended simple 
incision of the mucous membrane, or of the fissure, as a 
remedy in anal fissure. As has already been noticed, he 
advised the fissure or fissures to be excoriated with the 
nails, or incised or scarified with a cutting instrument. 
(Chirurgi Methodus Medendi, Lib. IL, cap, 8i,/>. 633, Chan- 
ning's Edition?) 

iEtius, however, of all the ancients, has given the most 
comprehensive account of condylomata and fissures of the 
anus. When speaking of the latter he seems to have 
already had reference to spasmodic contraction of the 
sphincter ani. He advises the old fissures to be treated by 
paring, or by scarifying their edges with a sharp instrument, 
and then applying suitable dressings, &c. (Medici Graci 
contracted ex veteribus Medicine 'Tetrabiblos hoc est Quarternio. 
Tetr. W., serm. 2, cap. 3. Basil, 1542. Folio. ,) 

I would now ask, what have the moderns any better, so 
far as the treatment of anal fissure is concerned, than the 
ancients had ? The main indication in the treatment of 
this disease then was precisely what it now is, — namely, 
to convert the original fissure into a recent wound. This the 
ancients accomplished by incising or scarifying the fissure, 
and by making various applications to it. It is here worthy 
of remark, that a fresh wound made in the diseased mucous 
membrane, or in the irritable fissure of the same, is not 
attended with the same severe suffering after the act of 
defecation, that arises from the original fissure or idiopathic 
disease. The ancients seem to have made the discovery 
that such a wound produced at first nothing more than a 
common soreness, but it at the same time entirely relieved 
the pain and cured the original disease, — hence they recom- 
mend and practised incision or scarification of the fissure, 
the same as now advocated and adopted by many at the pres- 
ent day. On the authority of the late Sir Benjamin Brodie, 
the late Mr. Copeland was the first surgeon who, in modern 



ANAL FISSURE. 11 

times, advised incising the mucous membrane simply, 
through the fissure, instead of complete division of the 
sphincter of the anus, as advised by M. Boyer. The an- 
cients also used various applications, as before observed, to 
the fissure, which, by converting the primitive or original 
lesion into a recent or fresh one, thus ultimately healed it. 
If the fissure is even attended by a spasmodic contraction 
of the sphincter ani, all that is necessary, as a general rule, 
to effect a radical cure, is to heal the fissure, and the anal 
spasm will cease of itself. 

Now, it will at once be perceived that, if the ancients 
taught such dogmata in relation to anal fissure as represented 
by M. Boyer, they were entirely ignorant of the nature, 
cause, and treatment of this disease. But before passing 
this severe judgment upon the tenets of our great fore- 
fathers in medicine, it would be well for us to investigate 
their doctrines on this subject more accurately than M. 
Boyer appears to have done in this instance. My opinion 
is, that the views held by the ancients with regard to the 
nature, cause, and treatment of this disease, although more 
or less mixed with error, were more rational than those 
promulgated by M. Boyer himself. It is true that the 
ancients do not give so full and so graphic a description of 
it as he does, but they may have thought that the simpli- 
city of the disease did not require it at their hands. From 
what M. Boyer says, he doubtless believed that he himself 
was the first surgeon who made the discovery, and who 
subsequently taught the doctrine, that anal spasm always 
accompanied anal fissure, that it was its characteristic or 
pathognomonic sign; indeed all his admirers attribute to 
him the origination of this idea of including spasmodic 
contraction of the sphincter ani — this sine qua non of his — 
in the term fissura ani. In this, however, as in some other 
opinions relative to this subject, he and they are most 
egregiously mistaken, for I will now show that nearly three 



12 ANAL FISSURE. 

hundred years before he promulgated this idea, the disease 
called anal fissure was described as not only consisting of a 
painful or irritable ulcer or fissure, but also of a contraction 
of the anus. Had M. Boyer consulted the works of his 
own countryman, the celebrated surgeon Pare, who flourished 
about the year 1 552, he would have found almost as 
graphic a description of fissure of the anus as that which 
he himself has given. I regret I have not a French copy 
of the works of Pare to quote from, but am obliged to 
use the English translation by Mr. Johnson, which is said, 
however, to have been translated from the Latin and care- 
fully compared with the French edition. Pare under the 
head, — " Chapps, and those wrinkled and hard Excrescences which 
the Greeks call Condylomata" says : — " Chapps or fissures are 
cleft and very long little ulcers, with paine very sharpe and 
burning, by reason of the biting of an acride, salt and dry- 
ing humour, making so great a contraction, and often times 
narrowness in the fundament and necke of the wombe, 
that scarcely the toppe of one's finger may be put into the 
orifice thereof, like unto pieces of leather or parchment, 
which are wrinkled and parched by holding of them to 
the fire. They rise sometimes in the mouth, so that the 
patient can neither speake, eat, nor open his mouth, so that 
the Chirurgian is constrained to cut it. In the cure thereof, 
all sharpe things are to be avoided, and those which mollifie 
are to be used, and the grieved part or place is to be 
moistened with fomentations, liniments, cataplasmes, em- 
plasters, and if the malady bee in the wombe, a dilater of 
the matrix, or pessary must be put thereinto very often, so 
to widen that which is over hard, and too much drawn 
together or narrow, and then the cleft little ulcers must be 
cicatrized." (The Workes of 'That Famous Chirurgion Ambrose 
Pare. Translated out of Latin and compared with the French. 
By Th. Johnson. Book XXIF., Chap. Ixiii., p. 957. London, 1634. 
Folio.} It is thus seen that M. Pare here furnishes us with 



ANAL FISSURE. 13 

a brief, yet a very comprehensive and correct description 
of anal fissure, consisting of cleft and very long little ulcers, 
situated in the orifice and canal of the anus, attended by 
very sharp burning pain, and often by great contraction or 
narrowing of the anus. M. Boyer has, as I have previously 
shown, emphatically declared that previous to his time anal 
fissure, as it was presented to him in the numerous cases 
which he treated, was unknown; inasmuch as he had 
sought in vain, in the writings of the ancients as well as in 
those of the moderns, to find a description of it ; and M. 
Blandin, one of his admirers, says that spasm of the 
sphincter ani, one of the varieties of anal fissure, was un- 
known till lately. M. Blandin also says that M. Lemonnier 
was really the first surgeon who has given any description 
of fissura ani. From this it is evident that M. Blandin 
was ignorant that M. Pare, one hundred years before, had 
given a much better description of anal fissure. M. 
Velpeau also, in alluding to M. Boyer's description of fissure, 
says that fissure of the anus was not in reality known as a 
distinct disease until after the year 1822. I, however, have 
shown that M. Pare, three hundred years before 1822, gave 
as correct a description of anal fissure as M. Boyer or any 
one else. 

For the treatment of this disease M. Pare recommends 
various applications to be made to the fissure, the dilatation 
of the contracted orifice, cutting, and the cicatrization of 
the ulcer or ulcers. I ask, what more is known of this 
disease at the present time ; or what more is done to relieve 
it, than we find briefly stated by M. Pare*? The same 
disease, says this quaint author, attacks the neck of the 
womb, and requires the same kind of treatment. I myself 
have for a number of years adopted the idea which is here 
singularly enough suggested, that the disease which is im- 
properly denominated Dysmenorrhea, is in reality nothing 
more nor less than fissure of the os tinea ; and I have so treated 



14 ANAL FISSURE. 

it with remarkable success, — namely, by the application of 
a strong solution of the nitrate of silver three times a week, 
and gentle and gradual dilatation with an elastic bougie 
once or twice a week. That dilatation exerts a powerful 
influence in curing dysmenorrhoea, is evidenced by the 
known fact that if the patient could become pregnant and 
give birth to a child she would be cured. In painful men- 
struation, there will almost always be found, besides spas- 
modic contraction of the os tincse, either fissures, abrasions, 
excoriations, inflammation, or tumefaction. 

Mr. Mackintosh, so long ago as in 1823, gives in his 
very able work on the " Principles of Pathology and Practice 
of Medicine" an ingenious theory on dysmenorrhoea. He 
believes that in this disease there exists constriction of the 
canal of the cervix uteri, — hence he practised dilatation 
with much success. I am aware, however, that there are 
those who look upon dilatation of the os tincse by a bougie 
with great distrust, considering it as a very dangerous and 
hazardous operation; yet strange, passing strange, these 
very same surgeons do not hesitate for a moment to thrust 
into the os tincse a large prepared sponge tent, which is 
known to be attended by far greater danger than by the 
gentle and gradual dilatation of an elastic bougie. 

M. Pinel Grandchamp, on the authority of Mr. F. Le 
Gros Clark, entertains a similar opinion in relation to the 
liability of fissure attacking the vulva, that M. Pare did in 
relation to its liability of attacking the os tincse. Mr. F. 
Le Gros Clark says that, — " This fissure, connected with 
painful spasm of the sphincters of the anus, had been ob- 
served only in the anal region, until M. Pinel Grandchamp 
remarked a similar condition of the vulva, where the con- 
striction was so firm that the marriage rites could not be 
fulfilled. Feeling convinced of the analogy of this case 
with stricture of the anus, Grandchamp made a deep in- 
cision, dividing the commissure, the mucous membrane, 



ANAL FISSURE. 1J 

and the sphincter of the vulva, to the extent of two inches. 
The contraction was cured, and the parts resumed their 
normal condition." {Baron Dupuytren's Clinical Lectures. 
Translated by F. Le Gros Clark, p. 149. London, 1845.) But 
I must stop here, as this digression has perhaps already been 
carried too far. 

For the purpose of the better elucidation of this subject, 
I would observe here that anal fissure might be distinguished 
into two stages. In the first stage the idiopathic disease of 
the mucous membrane, or muco-cutaneous coat of the part, 
has not yet arrived at that degree of irritation or excitation 
as to result in communicating its excitability to the muscular 
coat, or to the fibres of one or both sphincter ani muscles, 
inducing in them spasmodic contraction; for after the first 
manifestation of the disease, some time must necessarily 
elapse before spasmodic contraction takes place, and this 
period, be it longer or shorter, constitutes the first stage of 
the disease. In the second stage the primary disease has 
arrived at that extreme degree of excitability as to induce 
spasm of one or both sphincters of the anus, after every 
movement of the bowels, or other disturbance of the parts. 
Any idiopathic disease of the mucous membrane of the 
inferior extremity of the rectum, immediately over or 
within the grasp of the sphinctores ani, is liable sooner or 
later to become so irritable as to induce spasm of those 
muscles; indeed, disease in the genito-urinary organs is 
liable also to produce the same, and often does. The chief 
error, then, of the ancients consisted in omitting the second, 
or that stage manifested by anal spasm ; that of some of 
the moderns, in considering the second or spasmodic stage 
as the real or idiopathic disease, and so treating it ; whilst 
the error of other moderns again consists in considering 
each stage as a separate and independent disease, denomi- 
nating the first, anal fissure, and the second, spasmodic or 
gainful contraction of the sphincter ani. 



]6 ANAL FISSURE. 

I have already given what in my opinion were the reasons 
why the ancients omitted anal spasm in describing anal 
fissure, — namely, that they considered it as a different or an 
independent disease altogether, as many of the moderns 
have since done and now do. This, however, is conjecture 
merely, as there is no positive evidence of it in any of 
their writings, as far as my knowledge extends. 

Our attention will now be turned to the theory of those 
of the moderns who teach that anal spasm, the second stage 
of anal fissure, is itself in reality the idiopathic or real dis- 
ease, of which the breach of surface, or fissure, if any 
exists, is but an accidental accompaniment, or consequence, 
&c. This spasmodic contraction, however, is a phenomenon 
which may or may not accompany fissure of the anus. It 
is not the anal spasm that constitutes the disease, for anal 
fissure may exist without this arbitrary contraction; but 
such contraction of the sphinctores ani never exists without 
an irritable fissure, an inflammation, a tumefaction, or some 
other primary disease of the inferior extremity of the 
rectum ; or of some disease of the genito-urinary organs. 
This is the true doctrine, notwithstanding the declarations 
to the contrary of such highly eminent surgeons as MM. 
Boyer, Dupuytren, Brodie, and others. Their declarations, 
however, have never been verified in any one instance by 
any satisfactory ante- or post-mortem examination, and rest 
merely upon assertion. I have very carefully examined, in 
every conceivable manner, a large number, of cases, some 
under the influence of anaesthetics and others not ; and I 
have yet to observe the first case of painful spasm of the 
anus, that could not be plainly traced to primary disease in 
the mucous membrane of the part, or to some disease in 
the genito-urinary organs. These authorities seem to fix 
their whole attention on the local spasm of the sphincter 
ani, as if that condition of the muscle constituted the 
essence of the disease of which it is in truth only a symp- 



ANAL FISSURE. IJ 

torn ; hence their whole treatment is directed to the meas- 
ures to remove the spasm, instead of such as would attack 
its cause, the real disease. On this subject, however, M. 
Boyer seems to have some doubts, not being so emphatic, 
so decided, as MM. Dupuytren and Brodie. He says, — 
"Si nous mettions plus d'importance a suivre un ordre 
tres methodique, qu' a bien caracteriser une maladie incon- 
nue jusqu'a present, nous n'aurions pas commence cet article 
par la description de la fissure. En effet, la gercure de 
l'anus est constamment accompagnee de la constriction 
spasmodique des sphincters ; mais cette constriction existe 
quelquefois sans gercure, peut-etre meme celle-ci n'est-elle 
qu'un effet ou une complication de la premiere. Nous 
avons observe bien plus souvent la fissure, ou, si l'on veut, 
la constriction avec fissure, que la constriction sans fissure. 
Nous avons trouve entre le nombre relatif de ces deux ma- 
ladies, ou de ces deux etats de la meme maladie, le rapport 
de neuf a un : voila notre excuse. II est probable cepen- 
dant que, lorsque la constriction et la gercure existent, ces 
deux affections n'ont pas commence simultanement ; ou la 
gercure a araene la constriction, ou la constriction a precede 
la gercure ; de sorte que l'une de ces affections serait prim- 
itive, et l'autre accessoire ou consecutive ; mais je n'ai jamais 
vu de gercure sans constriction, et j'ai plusieurs fois ren- 
contre celle-ci sans fissure. L'incision des sphincters fait 
disparaitre la fissure, sans qu'il soit necessaire de porter sur 
elle l'instrument tranchant. 

" On pourrait presumer d'apres cela, ce me semble, que 
l'affection principale est le resserrement spasmodique." — 
(Traite des Maladies Chirurgicales. ^ome Fl. p. 609. Cm- 
quieme Edit. Paris \ 1849.) 

On this subject M. Dupuytren says: — "La gravite de 
cette affection depend done principalement du spasme dou- 
loureux des constricteurs de l'anus ; la fissure n'est meme 

qu'un accident ; ce qui le demontrerait e'est l'existence de 

2 



l8 ANAL FISSURE. 

la constriction douloureuse sans gereure, qui, d'apres des 
chirurgiens celebres, serait a l'autre cas comme l est a 4." 

And again M. Dupuytren says : — " La constriction spas- 
modique du sphincter, avons-nous dit, est la lesion veritable ; 
(l'ulceration alongee, nommee fissure ou gercure, n'est qu'un 
phenomene secondaire." — (Lecons Orales de Clinique Chirurgi- 
cale. Tome III. Article X. pp. 51-52. Bruxeltes, 1836.) 

I have presented MM. Boyer and Dupuytren fully and 
fairly in their own language, and it will be perceived that 
they both teach that the spasmodic contraction of the 
sphinctores ani muscles is the primary or real disease, and 
that the elongated ulcer called fissure of the anus is but a 
secondary phenomenon. They believed that by curing the 
anal spasm the disease was cured ; hence M. Boyer pro- 
posed to remove the constriction by the complete division 
of the two sphincters of the anus with the bistoury ; whilst 
M. Dupuytren proposed to fulfil the same indication by the 
anti-contractile property of belladonna, applied to the parts in 
the form of his celebrated ointment, prepared according to 
his favorite formula, as follows : — 

Recipe, Extracti Belladonnae, 

Pulveris Plumbi Acetatis, ana, drachmam unam, 
-'' ■ Adipis Suillae, drachmas sex. 
Misce et fiat unguentum. 

It will be observed that whilst the theory of these two 
celebrated surgeons is nearly identical, the treatment of each 
differs very essentially; that of M. Dupuytren is the most 
rational, however, and has in several respects decidedly the 
advantage, inasmuch as his ointment, while it tends to relax 
the constricted muscles, at the same time heals the fissure, 
which is the primary cause of the constriction, is attended 
with but little danger and leaves no subsequent bad results. 

Sir Benjamin Brodie considered the elongated ulcer, 
called fissure of the anus, as the result of the spasmodic 
contracted and hypertrophied sphincter ani; and to the 



ANAL FISSURE. K) 

morbid action of this muscle he ascribed the severe suffer- 
ing and distress which always attend anal fissure. — {Clinical 
Lectures on Surgery. Led. xxxvi. p. 322. Philadelphia Edition, 
1846.) 

I will now present the opinions of MM. Blandin, San- 
son, Quain, and Bushe on this subject, in opposition to the 
theory of MM. Boyer, Dupuytren, and Brodie. 

M. Blandin makes the following very pertinent remarks 
on this subject. He says : — " Suivant M. le professeur 
Boyer, dont l'opinion est d'un si grand poids dans tout ce 
qui a trait a notre science, et a ce point de chirurgie en par- 
ticulier, la constriction spasmodique de l'anus precede le 
developpement des fissures les plus graves, et doit en etre 
considered comme la plus remarquable predisposition. II 
est impossible de douter que cet etat de l'anus, lorsqu'il 
existe, ne dispose a la fissure, mais nous ne pouvons nous 
empecher de dire ici que nous croyons que le spasme de 
l'anus est bien plus souvent Peffet que la cause de la fissure 
a l'anus. La contraction spasmodique du sphincter arrive, 
parce que l'anus est irrite par l'inflammation de la fissure ; 
elle est tres-forte quand la fissure est tres-enflammee, surtout 
elle s'accroit par le passage des matieres fecales pendant les 
excretions, pour la merae cause. Le sphincter anal se con- 
tracte sous Pinfluence de l'irritation de la fissure, comme 
l'estomac, comme l'intestin se contractent lors de l'irritation 
ou de l'ulceration de la tunique muqueuse qui les tapisse. 
Que si Ton objectait que certaines fissures seulement sont 
accompagnees de la contraction spasmodique du sphincter, 
nous repondrions que la chose ne doit point surprendre ; 
car le sphincter se ressent seulement de l'influence de l'irri- 
tation de la muqueuse qu'il embrasse, et que par con- 
sequent les fissures qui lui sont superieures ou infe- 
rieures, ne devaient pas etre accompagnees de la con- 
traction, tandis qu'il en devait etre et qu'il en est autre- 
ment de celles qui siegent en dedans de lui." — (Dictionnaire 



20 ANAL FISSURE. 

de Medecine et de Chirurgie Pratiques. Home Fill. p. 157. 
Paris, 1832.) 

M. Sanson says : — " Nous croyons au contraire que la 
fissure ou au moins l'irritation de la partie, precede et pro- 
voque la constriction spasmodique." — (Nouveaux Elements de 
Pathologie Medic o-Chirurgic ale. Home III. p. 635. Quatrieme 
Edit. Paris, 1844.) 

The able and distinguished Mr. Ouain is very clear and 
very emphatic upon this subject, and his argument is indeed 
unanswerable. He says : — " The spasm of the sphincter 
in fissure is no more the actual disease than the spasm of 
the orbicidaris palpebrarum is that curious and painful malady 
so often met with among children, strumous ophthalmia. 
The passage of fecal matter is in the one case, what the 
stimulus of light is in the other. The muscular contraction 
is equally intense in both ; and the division of the muscle 
is no more necessary for the cure of the one, than of the 
other. Doubtless the spasm very largely aggravates the 
suffering in both instances. Its cessation, however, in the 
complaint (fissure) we are especially engaged with, by di- 
vision of the ulcer and the mucous membrane only, proves 
sufficiently that the muscle is not the seat of the disease." 
— (Hke Diseases of the Rectum. Second Edition, p. 176. New 
Tori, 1859.) 

Dr. Bushe on the same subject says: — '' To me it appears 
illogical to assert that fissure is the consequence, or a com- 
plication of spasm, because the fissure is always accom- 
panied with spasm, and spasm sometimes exists without 
fissure. Now that spasm may cause fissure, I have before 
explained ; but that fissure may arise from other causes, is, 
I think, beyond dispute." — {A Treatise on the Malformations, 
Injuries, and Diseases of the Rectum and Anus, p. 120. New 
Tori, 1837.) 

M. Velpeau, in order to reconcile somewhat these several 
conflicting views, says : — " Perhaps, however, there may be 



ANAL FISSURE. 21 

some means of reconciling opinions on this interesting 
point in the history of fissure of the anus. Thus we can 
understand how a small fissure, being irritated by the pas- 
sage of stercoraceous matter, may excite spasmodic constric- 
tion in the muscular bands underneath it ; and again, we 
can believe that strong spasmodic contraction of the anus, 
by inducing constipation, may induce excoriation of the 
skin about the anus, and thus become a cause of fissure. 
Under this point of view contraction of the sphincter ani 
and fissure are two distinct affections which are independ- 
ent, but have a strong tendency to merge, one into the 
other." — (Clinical Lecture on Fissure of the Anus, in Provincial 
Medical and Surgical Journal. April 3, 1841.) 

This highly important subject will receive still further 
elucidation in the next section, while discussing the highly 
interesting question of the independent existence of anal 
spasm, especially as being a separate or distinct disease from 
anal fissure, as taught by a large number of the moderns. 

I would here remark that some of the authors whom I 
quote in this work make no distinction between the ex- 
ternal and internal sphincter ani, but speak of both muscles 
as one, as all the early anatomists do, which they call the 
sphincter ani, thus confounding both sphincters. When 
they speak of spasmodic contraction of the sphincter ani, 
they mean both muscles, and when they speak of incising 
the sphincter ani, they mean the same. It will be well for 
the reader to note this, and recognize this distinction. 



-0- 



SECTION II. 

SPASMODIC CONTRACTION OF THE ANUS. 

1. It is well known that nervous irritation in muscular parts 
often occasions partial and sometimes obstinate contractions ; 



22 ANAL FISSURE. 

and when this effect takes place in the anal canal, it consti- 
tutes what is generally called spasmodic contraction of the 
anus. In spasmodic contraction, inflammation and nervous 
irritation are always present in a greater or less degree. 
With regard to muscular contraction, I would observe that 
there are three varieties, which can be plainly distinguished 
in practice : the spasmodic contraction, which can always be 
dilated to the full size of the canal in which it exists ; the 
permanent or organic, which admits of no such dilatation, 
and the mixed kind, which partakes of the characters of 
both. The two last can not only be detected in life, but 
can be demonstrated post-mortem. Of the first, however, 
nothing can be learned by dissection after death, because 
the spasm depends entirely upon an active principle which 
ceases with life. It will be readily conceived how a purely 
spasmodic contraction may be converted into a permanent 
or mixed one. I am of opinion that a spasmodic contrac- 
tion almost always precedes a permanent or organic one, 
upon the principle that the parts, being held so repeatedly 
and so continuously in a contracted state, ultimately grow 
rigid and unyielding. Upon the same principle muscular 
fibres in other parts sometimes become fixed, of which we 
have an instance in irremediable trismus. 

2. Anal Spasm as an Entity — A Disease in itself. The in- 
dependent existence of spasmodic contraction of one or both 
sphincters of the anus is a theory held and taught by some 
of the most able surgical writers on the diseases of the rec- 
tum. But as the principle rests purely upon the evidence 
of facts, fairly and fully ascertained and set forth, they have, 
in my opinion, failed to establish it. The recorded cases 
and examinations which they present for the purpose of 
illustrating and confirming this doctrine, are not given with 
the detail and with the precision of language which are 
essentially necessary to render such evidence in surgery a 
substitute for personal experience. The confusion and 



ANAL FISSURE. 



2 3 



conflict of principles in their practical directions are so 
obvious that the most superficial observer cannot fail to 
perceive them; for under the head "Spasmodic Contraction of 
the Sphincter Ani" they enumerate the features of various 
diseases, not less different in their appropriate treatment 
than in their setiology and nature ; consequently their at- 
tempts at making out a clear diagnosis are a complete 
failure. 

I will now present the names of a number of able authors 
who have treated anal spasm as an entity — a disease in 
itself — and who have made it the subject of special consid- 
eration; and I will endeavor to prove that the numerous 
cases they present to illustrate this theory of anal spasm are 
in reality cases of anal fissure, or of some other disease of 
the mucous membrane of the inferior extremity of the rec- 
tum, or of disease in the genito-urinary organs, and not 
cases of primary or independent disease of the sphincter 
ani muscle itself; and that instead of the phenomenon of 
spasmodic contraction in these cases being an evidence of 
primary disease in the sphincter ani itself, it is merely a 
symptom, or a manifestation of disease in its vicinity. In 
extenuation, however, of the want of the proper knowledge 
on this subject on the part of these authorities, it may be 
observed that the great difficulty and extreme pain always 
attending an examination per anam, during the continuance 
of the spasm in these cases, precluded the possibility of 
making a minute inspection of the parts, so absolutely 
essential to rendering a clear diagnosis. This great diffi- 
culty and this severe pain are at the present day annihilated 
by the use of anaesthetics, and the now common use of the 
anal speculum as well as the rectal endoscope. 

Spasmodic contraction of the anus, besides being caused, 
as before observed, by disease of the mucous membrane of 
the inferior extremity of the rectum, is in some instances 
consecutive to disease in the genito-urinary organs, as will 



2\ ANAL FISSURE. 

be abundantly shown hereafter. As is well known, the 
rectum, in its course through the pelvis, lies in close relation 
with the prostate gland, vesiculcz seminales, bladder and urethra 
in the male, and with the uterus and the vagina in the female. 
The association of this organ with so many important viscera 
of the pelvis is so close, both in consequence of their prox- 
imity and their combined action in the performance of cer- 
tain functions, that any unusiial excitement of the latter 
organs is exceedingly liable to extend itself to the former; 
then how varied and how great must the sympathies be 
which result from this extensive and multiplied relation of 
contiguity. 

The first authority I shall adduce will be that of M. 
Boyer, as he stands at the head of the roll of eminent sur- 
geons who, in modern times, advocated the doctrine that 
anal spasm is an entity, an idiopathic disease, as I have 
shown in the preceding section. He treats of " Constriction 
with Fissure " and " Constriction without Fissure" and ascribes 
precisely the same symptoms to both ; but he makes the 
diagnosis between them to depend upon the presence, in 
the first, of fixed pain at some point in the contour of the 
anus or rectum, together with a breach of surface ; whilst 
in the last these are entirely absent. To illustrate and 
establish the doctrine that anal spasm is an idiopathic dis- 
ease — that is, "Constriction without Fissure" — he reports three 
cases which came under his own immediate observation. 
These cases, according to his arrangement or series, are 
numbered three, four, and five. In carefully reading the first 
of these, headed " Constriction sans gergure" I find that he 
makes no mention of having made any examination of the 
anus and rectum, and without such examination, how, I ask, 
could he determine whether there was a crevice or not ? He 
seems, however, simply to have taken it for granted that 
there was none; at least he presents no evidence whatever 
of this fact. This case must therefore be laid aside as of 



ANAL FISSURE. 2$ 

no value in this controversy. In the remaining two cases, 
four and jive, M. Boyer did make a digital examination of 
the rectum, consequently I will present them in full in his 
own language. 

" Obs. IV. — Constriction sansjissure. Laurent Cisterne eprou- 
va,a Page de trente et un ans, apres une longue constipation, 
( des douleurs vives a l'anus, que les efforts qu'il faisait pour 
aller a la selle rendaient atroces. Des ce moment, les eva- 
cuations alvines ne purent se faire qu'avec des souffrances 
inouies, qui duraient quatre a cinq heures. Lorsqu'il etait 
debout ou couche, il souffrait peu ; mais assis, les douleurs 
se faisaient sentir plus vivement : il crut done devoir quit- 
ter son metier de cordonnier." 

"Pendant trente mois, les laxatifs purent seuls produire 
quelque soulagement ; tous les autres remedes furent sans 
effet." 

"II entra a l'hopital de la Charite le 26 novembre, 1809. 
En explorant l'anus, je decouvris, du cote droit, un peu au- 
dessus de cette ouverture, un point dur, epais et comme cal- 
leux ; ce point etait tres-douloureux et le siege principal de la 
douleur pendant les selles. Le sphincter se contractait forte- 
ment sur mon doigt, surtout lorsqu'il pressait ce point dur. 
Je mis le malade a la diete et a l'usage des delayants; je pre- 
scrivis un leger purgatif, le lendemain un lavement, et le 
jour suivant je coupai le sphincter en travers sur le point 
dur, epais et douloureux, dont j'ai parle. La plaie se cica- 
trisa lentement; pendant quelque temps, les matieres fe- 
cales causerent, en passant sur la plaie et ensuite sur la cica- 
trice, quelques douleurs obscures ; mais cette partie cessa 
d'etre sensible, et lorsque, plusieurs mois apres sa sortie de 
l'hopital, cet homme vint nous voir, comme nous Ten 
avions prie, il etait parfaitement gueri." — (Op. Cit., p. 617.) 

" Obs. V. — Constriction sans jissure. Alexis Cuby, age de 
cinquante-deux ans, eprouvait depuis deux ans et demi en- 
viron, en allant a la selle, des douleurs qui, peu vives dans 



26 ANAL FISSURE. 

le commence ment, et se faisant sentir seulement par in- 
tervalles, devinrent tellement aigues que le malade les com- 
parait a un fer rouge qu'on lui aurait introduit dans le rec- 
tum. L'usage des lavements prepares avec des substances 
narcotiques ne procura qu'un soulagement passager ; tous 
les autres remedes furent egalement sans succes. Cuby vint 
me consulter; je lui disqu'une operation seule pourrait mettre 
fin a ses souffrances. 11 entra a Phopital de laCharite. L'anus 
etait tellement serre,que mon doigt ne penetra qu'avec peine 
et en causant de vives douleurs dans rintestin rectum. Vers 
le cote gauche, je crus sentir une gergure : c'est la que le 
malade pretendit eprouver les douleurs les plus aigues. 

" Apres avoir prepare le malade pendant quelques jours, 
je fendis le sphincter sur le point le plus douloureux, sur 
l'endroit meme ou j'avais cru rencontrer une fissure ; je fis 
continuer l'usage des meches pendant quarante et un jours. 
Cet homme sortit de 1'hopital peu de temps apres, pouvant 
aller depuis un mois a la garde-robe sans eprouver la moin- 
dre douleur." — {Op. Git, p. 618.) 

It will be plainly perceived from reading the graphic 
description given of these two cases by M. Boyer, that 
they were cases of fissura ani, attended by sympathetic 
spasm of the sphincter ani muscle or muscles, and not an 
idiopathic disease of these muscles themselves. It is dis- 
tinctly stated by M. Boyer, that increased pain was induced 
in each case by pressure with the finger upon a particular 
spot in the rectum ; and not only so, but he says he dis- 
tinctly felt, in one case, an induration at the tender point, 
and to which the patient referred all his sufferings ; in the 
other case he thought he felt a fissure, an excoriation, or an 
ulcer at the tender point, and at which the patient claimed 
to feel the greatest pain. 

These cases were not examined with the speculum ani ; 
indeed this was not necessary, as the digital examination 
was alone sufficient to determine them to have been disease 



ANAL FISSURE. 27 

of the mucous membrane. They therefore entirely fail, in 
my opinion, to exemplify the characteristics of the disease 
which this distinguished author intended them. 

The late and distinguished Mr. Copeland introduced the 
subject of anal spasm under the head, " Powerful or Dis- 
eased Action of the Sphincter Muscle." — {Observations on 
the Principal Diseases of the Rectum and Amis. Second Edition, 
pp. 48, 132. London, 1814.) Mr. Copeland considered the 
powerful or diseased action, as he calls it, of the sphincter 
ani, as an idiopathic affection of the muscle itself, the source 
of such action. His views upon this subject, however, are 
somewhat vague and uncertain, and he fails to make out a 
clear diagnosis. He fails to prove the independent exist- 
ence of muscular spasmodic contraction; and he also en- 
tirely fails to make that necessary distinction between a 
purely spasmodic contraction of the sphincter ani and a mixed 
contraction of the same — that is, one partly spasmodic, and 
partly organic, and a permanent or organic stricture of the 
anus, or anal canal. I will hereafter show how a purely 
spasmodic contraction of the sphincter ani may result in a 
permanent or organic stricture of the orifice and canal of 
the anus ; and also how the same muscle, from the continu- 
ance of the same cause, may become hypertrophied and in- 
durated. I will also show that the same muscle is some- 
times preternaturally large and active, the result of a con- 
genital malformation. 

Mr. Copeland reports three cases. The first case was 
evidently not a purely spasmodic contraction of the sphinc- 
ter muscle, at the time first seen by Mr. C, whatever it 
might have been originally. It was doubtless the result of 
chronic inflammation of the mucous membrane of the in- 
ferior extremity of the rectum, and the contraction, from 
being at first purely spasmodic, became more or less organic. 
The same may be said of his second case. In this case the 
principal contraction was five inches up the rectum, and 



28 ANAL FISSURE. 

the sphincter ani was found to be unusually strong and 
broad. The third case was that of a medical gentleman, a 
former pupil of the celebrated Mr. Pott. He describes 
his own case most graphically, and the agonizing pains he 
endured ; yet gives not the slightest intimation of what he 
believed to be the true nature and cause of his intolerable 
and exquisite suffering, more than remarking that his medi- 
cal friends considered it spasmodic. This was a case of 
real fissure of the anus, for a better description of anal fis- 
sure could not have been given than this medical gentleman 
gave of his own case. Had there been a proper explora- 
tion of the rectum made in this instance, the fissure would 
have been easily detected and as easily cured. Here the 
spasmodic contraction was not the real disease, but the 
mere effect or symptom of it. 

Mr. Copeland treated these cases rationally, by dilatation, 
with more or less success. 

Mr. Baillie reported a case of what he called, " Stricture 
of the Rectum, produced by Spasmodic Contraction of the 
Internal and External Sphincter of the Anus." — (Medical 
transactions of the College of Physicians of London. Vol. V. p. 
136. London, 1815.) x\fter giving a brief description of 
permanent organic stricture of the rectum, and before de- 
scribing the case in question, Mr. Baillie says : — " Another 
kind of stricture, however, occasionally occurs in the rec- 
tum, much less formidable in its nature, which is very rare, 
and has hitherto been taken little notice of by practitioners. 
This is not attended with any diseased structure of the 
coats of the rectum, but depends upon a contraction, more 
or less permanent, of the sphincters of the anus." — (Loc.cit) 
I do not agree with Mr. Baillie when he says that this kind 
of stricture (meaning spasmodic stricture) is unattended 
by any diseased -structure of the coats of the rectum, and 
that it depends upon a contraction, more or less permanent, 
of the sphincters of the anus. Mr. Baillie, like Mr. Cope- 



ANAL FISSURE. 2Q 

land, does not make that distinction between a purely spas- 
modic stricture or contraction, a mixed one, and a perma- 
nent or organic one, which is so necessary to a clear con- 
ception of the subject. This case of Mr. Baillie was 
doubtless originally purely spasmodic, but had become 
mixed. He makes the contraction in spasmodic stricture 
the primary, the real, or the independent disease. His own 
case, however, does not bear him out in this respect, for it 
was evidently a case of either anal fissure, or inflammation, 
or irritation of the mucous membrane of the rectum, or 
muco-cutaneous coat about the anus. He made no exam- 
ination of the rectum in this case, except a digital one, and 
that under the unfavorable circumstances of the anal con- 
traction being so great that the index finger was admitted 
with difficulty. A small fissure, hid in the folds of the 
canal, however, might very easily elude detection by the 
finger alone. The evident cause of the spasmodic and sub- 
sequent more or less permanent or organic contraction of 
the sphinctores ani muscles, in Mr. Baillie's case^ was the 
sudden translation of the herpetic eruption from the right leg of the 
patient to the anus and anal canal. This was the direct cause 
of the structural disease of the inferior extremity of the 
rectum in this case, and which gave rise, subsequently, 
to the spasmodic, as well as the more or less permanent 
contraction which resulted in this case. I will show here- 
after that cutaneous affections of the anus, or anal region, 
are often the cause of anal fissure as well as spasmodic and 
organic contraction of the anus. 

Mr. Gaitskell reported a case of what he termed " Spas- 
modic Contractions of the Sphincter Ani Muscle." — {Lon- 
don Medical Repository. Vol.W.p.$\. London, 18 1 5.) Mr. 
Gaitskell considered the spasmodic contractions in this 
case as a disease of the muscle itself; for he says in rela- 
tion to it, that he was induced to consult the valuable work 
of Mr. Copeland on the diseases of the rectum, in which, 



30 ANAL FISSURE. 

under the head "Disease of the Sphincter Muscle" he found a 
solution of the difficulties which he encountered in the 
early treatment of it. His description of this case, however, 
proves it to have been a clear case of anal fissure, for no 
one at all familiar with that disease could come to any other 
conclusion, after reading his plain description of it. His 
treatment was rational and effectual, not being the division 
of the sphinctores ani. He says he effected a cure of his 
patient by passing a large bougie up the rectum, night and 
morning, for two weeks, and keeping the bowels open by 
castor oil draughts. At first considerable relief was obtained 
by passing up the rectum, every evening, a small candle 
smeared with a liniment of almond oil, lime-water, and 
laudanum. 

Mr. Blackett reported a case of what he called, " Spas- 
modic Stricture of the Rectum."-— {London Repository. Vol. 
Vll. p. 377. London, 1817.) The spasmodic stricture or con- 
traction in this case was caused by rectitis, which was evi- 
dently the disease from which the patient suffered ; although 
Mr. Blackett gives no intimation whatever of this. I have 
in my practice witnessed several cases of spasmodic con- 
traction of the sphincters of the anus induced by inflamma- 
tion of the rectum and anus. 

Mr. White, under the head, " Different Forms of Con- 
traction," makes the following pertinent remarks : — " The 
most simple form of contraction which we meet with in 
the lower part of the intestinal canal, is that produced by 
spasm, which consists in an inordinate degree of contrac- 
tion in the muscular coat of the intestine, excited by some 
irritating cause. It happens, however, in ordinary cases, 
that the spasm ceases as soon as the exciting cause is re- 
moved. But when there is a frequent repetition, or a long 
continuance of the exciting cause, a permanent state of 
spasmodic stricture may be induced, and remain even after 
the exciting cause has ceased to act." 



ANAL FISSURE. 3 1 

" Though it is evident that any part of the canal may be 
liable to spasmodic contraction, from the nature of its 
structure, and the office to which it is destined, yet the 
complaint is found by experience to happen most frequent- 
ly towards its lower extremity. Very often a permanent 
spasmodic contraction occurs at the sphincter ani." — {Obser- 
vations on Strictures of the Rectum. 'Third Edition, p. 10, Bath, 
1820.) 

Mr. White is clearly of opinion that the spasmodic 
contraction of the muscular fibres of the rectum, or of 
the sphincter ani, is not a primary affection, but induced by 
some exciting cause, of whatever nature it may be, and 
that the spasm immediately ceases on the removal of such 
a cause. What Mr. White means by permanent spasmodic 
contraction, I cannot so clearly comprehend. I can very 
readily understand how the long and often repeated spas- 
modic contraction of the sphincter ani muscle, or of the 
circular fibres of the rectum, would ultimately result in an 
organic or permanent stricture or contraction of the anal 
orifice, or of the canal of the rectum. This contraction, 
however, would no longer be spasmodic, -but organic or 
permanent, having through the medium of inflammation and 
subsequent plastic exudation and thickening become so. 
In such a case the anus gradually becomes permanently 
contracted and more or less indurated, and in the exact ratio 
in which this organic change takes place, the spasmodic 
character of the case disappears. 

M. Delpech, the eminent Montpellier Professor, like 
Mr. White, alludes to the same subject. He says: — "Un 
spasme fixe du muscle sphincter externe de l'anus accom- 
pagne et peut-etre produit par une ou plusieurs gercures 
placees dans les rides rayonnantes de cette overture." {Precis 
J^lementaire des Maladies reputees Chirurgicales. Tome I. p. 598. 
Paris, 1816.) 

Mr. Howship reports two cases of what he calls "Ex- 



32 ANAL FISSURE. 

treme Hemorrhoidal Irritation." I will present a part of 
his description of the first case : — " November 23d, 1822, I 
was requested by Mr. Hardy, of Walworth, to visit a young 
lady, a patient of his, who had previously seen several 
physicians and surgeons, having for nearly six months suffer- 
ed the most extreme distress and pain, apparently from some 
very small hemorrhoidal tumors. To alleviate her misery 
every internal medicine, capable either of allaying pain or 
regulating the action of the bowels, and every anodyne, 
sedative, or astringent local application, had been tried with- 
out affording the least relief. The tongue was white ; the 
pulse was one hundred, small and weak ; the strength and 
flesh rapidly wasting. 

" On examining the parts outwardly, I at first conceived 
there was a small hard tumor behind the integuments at 
the margin of the sphincter; but, the finger gently passed 
into the bowel, it turned out to have been a spasmodic and 
painfully contracted state of the sphincter, which, once 
overpowered, became relaxed, thin, and comparatively 
painless. The hemorrhoidal tumors, as Mr. Hardy ob- 
served, were too inconsiderable to explain so much distress 
as this young lady had suffered. 

" The state of this young lady's habit was evidently 
irritable, and although opiates had failed to relieve, it ap- 
peared to me probable the temporary suspension of spasm 
by dilatation of the sphincter might be useful, and perhaps 
do more than was expected." — (Practical Observations on some 
of the Diseases of the Lower Intestines and Anus. 'Third Edition, 
p. 240. London, 1824.) This interesting case of Mr. How- 
ship was no doubt a plain case of anal fissure accompanied 
by anal spasm and condylomata or anal excrescences, and 
not a case of haemorrhoids. Had a careful examination of 
the anus and rectum been made in this instance, a fissure 
would doubtless have been discovered. The treatment of 
this case was by dilatation, perseveringly carried out by the 



ANAL FISSURE. 33 

use of wax tapers and a metallic bougie five-eighths of an 
inch in diameter. This treatment succeeded in relieving 
the spasm, and to a great extent the pain. 

Mr. Calvert, under the head, " Morbid Contraction of 
the Anus," introduces the subject of spasmodic contraction 
of the sphinctores ani muscles. — (A Practical treatise on 
Hemorrhoids, Strictures, and other important Diseases of the 
Rectum and Anus, p. 210. London, 1824.) 

Mr. Calvert considers spasmodic contraction of the anal 
sphincters to be an idiopathic, or a substantive disease ; but 
he entirely fails to establish a correct or satisfactory diag- 
nosis ; indeed, he appears much confused and undecided 
respecting the nature, cause, and treatment. He says : 
" With regard to the mode of treatment of cases of spas- 
modic contraction of the sphincter muscles, it is very un- 
certain in the result, unless when it is evidently connected 
with inflammation ; nothing that is decidedly advanta- 
geous and generally applicable can be gleaned from past 
experience ; and amongst the very few who have noticed 
this complaint, a considerable difference of opinion exists. 
As it is frequently connected with fissures of the inner 
membrane of the anus, it has been supposed by some prac- 
titioners that these are the cause, whilst others have con- 
sidered them to be a consequence of the contraction, and 
have been influenced accordingly with regard to the 
means of cure most likely to be attended with success." 
— (Of. cit. p. 226.) And again Mr. Calvert remarks : 
" Although this form of contraction of the anus is 
often connected with fissures, yet as it sometimes 
exists separately, it is evident that these, when present, 
cannot with any degree of certainty be considered as 
the cause, and that we cannot conclude the complaint 
will disappear if these are cured." — (Op. cit. p. 229.) 
From this conclusion of Mr. Calvert I dissent in toto. 
We can most certainly conclude that if the fissures, die 

3 



34 ANAL FISSURE. 

cause, are cured, the spasmodic contraction, the effect, will 
sooner or later cease. 

Mr. Mayo, under the head, " Stricture of the Rectum," 
introduces the subject of spasmodic contraction of the sphinc- 
ter ani, which he says is a kind of cramp; and from the 
fact of presenting it under the above head, and not under 
that of "Fissures of the Rectum," he considers it a separate 
and distinct disease from rectal or anal fissure. — {Obseroations 
on Injuries and Diseases of the Rectum, p. 184. London, 1833.) 

It is remarkable that so acute an observer as Mr. Mayo 
should have entirely overlooked the phenomenon of spas- 
modic contraction of the sphincter ani when treating of 
"Fissures of the Rectum," in the previous part of his 
work. He reports three cases of fissure, in the last of 
which there existed positive spasm of the sphincter ani ; 
yet in his description of fissure he does not mention spasm 
as ever attending that disease. His treatment of rectal 
fissures, as he termed the disease, consisted in the applica- 
tion of the solid nitrate of silver, or mercurial ointment, 
and on these failing, then division of the sphincter ani 
muscle. — (Op. cit. p. 2.) 

Chelius introduces the 'subject of anal spasm, under the 
head, " Narrowing and Closure of the Rectum." — (Hand- 
buck der Ckirurgie, Band 11, S. 34. Heidelberg und Leipzig, 1827.) 
He does not treat of anal fissure at all, only in connection 
with spasmodic contraction of the anus, of which he believes 
the anal fissure to be the exciting cause when present, and 
that it is almost always present. Although he presents spas- 
modic contraction of the anus as an idiopathic disease, yet he 
seems to have strong doubts of it; says its causes are very 
obscure, and that he has ascertained by experience that it 
is oftener the consequence of seemingly insignificant causes 
— such as small ulcers, fissures, excoriations, and small ex- 
crescences, than is generally believed. In this I fully agree 
with him. He also says that he has ascertained that by 



ANAL FISSURE. 3_J 

curing the fissure, or by removing the excrescences, &c, 
the anal spasm will at once cease. This is precisely my 
experience too. But he says that if such treatment is too 
long delayed, nothing short of the complete division of the 
anal sphincter will cure the complaint. In this I by no 
means agree with him. 

Mr. Salmon reports a case of contracted sphincter ani, 
the subject of which was a medical officer of the British 
army. This case is reported in the language of the patient 
himself — (A Practical Essay on Stricture of the Rectum, Fourth 
Edition, p. 81. London, 1833.) 

This was evidently a case of anal fissure, complicated 
with condylomata and anal fistula, a not unusual complica- 
tion, as I will show in numerous instances in subsequent 
pages of this work. Had the attendants of this patient 
examined carefully the base of the external hemorrhoid 
(excrescence), which he names in describinghis own case, they 
would have detected the inferior extremity of an anal fissure, 
which would have led them at once to the true source: of 
all his agonizing and protracted suffering. Mr. Salmon 
considered the anal spasm, or contraction, in this case to be 
an idiopathic disease of the muscle itself; entertaining the 
erroneous belief that the whole of this patient's suffering 
originated in the morbid condition of the sphincter externa s 
itself; hence he advised and executed the irrational and 
mischievous operation of the division of the sphincter exter- 
nus. It is true, the patient says that this operation relieved 
him of his present suffering ; yet it is equally true that he 
might have been entirely relieved by a milder, safer, more 
certain and more rational treatment. 

Our late distinguished fellow-citizen, the lamented Dr. 
Bushe, treats spasmodic contraction of the sphincter ani as 
an idiopathic disease, considering it, in some instances, sep- 
arate and distinct from anal fissure, and from neuralgia of 
the inferior extremity of the rectum ; but his diagnosis is 



36 ANAL FISSURE. 

too vague to be appreciated. He says he has demonstrated 
that spasmodic contraction of the sphincter ani may be 
produced by fissure, and that he has proved it to be occa- 
sionally the consequence of neuralgia; but, says he, ** be- 
sides these there are two other species of spasmodic con- 
traction of the sphincter — namely, that which depends upon 
functional or structural disease of the genito-urinary organs; 
and that in which we cannot trace any other primary affec- 
tion, either in the rectum or elsewhere." He then reports 
six cases of spasmodic contraction of the sphincter ani, in 
which the genito-urinary organs were primarily affected. 
He next reports four cases, in which he says he could not 
discover any other primary disease, and then concludes by 
saying that, "as these four cases now related are the only 
substantive forms of spasmodic contraction of the sphincter 
ani that I have observed, I am disposed to consider it as a 
rare disease." — (A treatise on the Malformations, Injuries, and 
Diseases of the Rectum and Anus, f p. 119, 128. New Tori, 

18370 

Dr. Bushe rests the question of the independent existence 
of anal spasm entirely upon these four cases. But where are 
the proofs of the substantive form of the muscular spasm 
in these cases ? It is not by any means a necessary conse- 
quence that, because he failed in these cases to trace the 
anal spasm to any primary affection, no such affection 
existed ; or that on this account the spasmodic contraction 
must necessarily be the primary disease itself. The pre- 
sumption is that anal spasm is always the result of some 
primary disease of the mucous membrane of the rectum, 
or muco-cutaneous coat about the anal orifice ; or of some 
primary disease in the vicinity of the rectum and anus, 
whether we can trace or detect such primary affection or 
not; indeed, the spasmodic contraction of the anus is a 
positive evidence that such is the fact. To show how 
valueless are the assertions of Dr. Bushe, he made no 



ANAL FISSURE. 37 

examination whatever of the anus and rectum in the first 
and second cases ; consequently these two cases prove no- 
thing. In the third case he admits that the anus was 
closed so firmly that the finger could only be entered with 
great difficulty; consequently no fair or satisfactory exam- 
ination could be made under such circumstances. In the 
fourth and last case Dr. Bushe says that an examination was 
made carefully, but no structural disease could be discover- 
ed, as the pressure with the finger in the rectum produced no 
more pain in one part than in another, as all the parts touch- 
ed were painful alike. But was not this diffused pain upon 
pressure evidence of disease of the mucous lining of the 
whole circumference of the inferior extremity of the rec- 
tum; and was not the spasmodic contraction in these two 
cases merely consecutive to it*? I have no doubt whatever 
of this. A proper examination of the rectum with the 
speculum in these two cases, the patients having been under 
the influence of an anaesthetic, would doubtless have re- 
vealed this condition of the mucous membrane. Dr. Bushe 
in the exploration of these cases used no speculum ani, and 
no surgeon should affirm positively that no disease of the 
mucous membrane of the lower portion of the rectum 
exists, because he fails to detect it with the finger ; for 
such disease may sometimes exist, and the surgeon entirely 
fail to detect it with the finger alone, several examples of 
which have come under my own observation. These 
cases, then, of Dr. Bushe, which were presented to show 
that there was no primary disease either in the rectum or in 
the genito-urinary organs to account for the spasmodic con- 
traction, entirely fail, in my opinion, to do so. They fail 
to exemplify the characteristics of the disease for which they 
were adduced. They are indeed examples, not, however, of 
an idiopathic affection of the sphincter ani muscle, but of 
some primary disease of the mucous membrane of the part, 
or some primary disease in some of the adjoining organs, 



38 ANAL FISSURE. 

attended merely with sympathetic spasmodic contraction of 
the sphincter ani muscle. Well may Dr. Bushe then say 
that he considers as rare the spasmodic contraction of the 
sphincter ani, as a substantive form of disease. 

Mr. Curling introduces the subject of spasmodic contrac- 
tion of the sphincter ani muscle under the head, " Irritable 
Sphincter Muscle" Although he presents it as an idiopathic 
disease, his diagnosis is anything but clear. This is evident 
from the conclusion to which he arrives. He says : " Irrita- 
bility of the sphincter occurs commonly in hysterical 
females, or in nervous, susceptible women who are accus- 
tomed to watch and to intensify every sensation. I have 
seldom met with it in other persons independently of 
some local source of irritation, as an ulcer, or an inflamed 
internal pile; and I believe that in men, simple irritability 
of the sphincter muscle is a rare complaint. The investi- 
gation of such a case is seldom satisfactory without an ex- 
amination of the rectum with the speculum ; and in most 
instances of irritable sphincter, I am convinced that some 
direct cause of irritation may be discovered by this means." 
— {Observations on the Diseases of the Rectum, tfhird Edition, 
p. 15. London, 1S63.) With some of the sentiments of 
this very able and distinguished surgeon on this subject, as 
expressed above, I most cordially agree; but I believe that 
not only in most instances, but in every instance, if 
thoroughly examined and investigated, a direct cause, out- 
side of the sphincter muscle itself, can always be found to 
account for the phenomenon of the spasmodic contraction. 

Mr. Malyn, under the head, "Spasm of the Anus" intro- 
duces the subject of spasmodic contraction of the sphinctores 
ani muscles. His views are interesting, and deserve candid 
consideration. He says : " Spasm of the anus, it seems 
probable, is mostly the consequence of some preceding 
morbid irritation, situated either in the gut itself, or in some 
of the organs with which it is interested; and it conse- 



ANAL FISSURE. 39 

quently ceases when that irritation is removed. Such is the 
case when the urinary or genital organs are excited ; for 
though the sphincters, especially the external one, always 
participate more or less in the disturbance of those organs, 
their spasmodic action ceases when the others have regained 
their quiescence." "There appears, however, to be pro- 
duced sometimes by an insidious and long-continued irri- 
tation in the intestine, or by the degrading broodings of a 
licentious mind, a spasmodic condition of the extremity of 
the rectum, which becomes a cause of its own continuance 
by reason of the inflammation which has been set up in 
the parts, and which their state of activity will not allow 
to subside. In this condition when by removing the cause 
alone, we do not remove the effect." — (jTke Cyclopedia of 
Practical Surgery. By W. B. Costello, M.D. Vol. 1. Article 
Anus, p. 339. London, 1841.) 

Mr. Malyn looks upon anal spasm, occurring under cer- 
tain circumstances, somewhat in the light of a substantive 
form of disease, and thinks that on this account it merits 
separate and distinct consideration ; yet, with all his inge- 
nuity, he fails to make it appear an independent disease or 
an entity, a disease in itself. I agree with Mr. Malyn, that 
in anal spasm the effect may under certain circumstances 
become more or less a cause, and a cause too of its own 
perpetuation to a certain extent — that is, it may aid by its 
long continuance in bringing about a morbid condition of 
the parts, consisting in inflammation, congestion, and ex- 
quisite irritability; so that, even if the primary cause should 
be removed, this, morbid condition, the secondary cause, 
might still remain to keep up the spasm which aided in 
bringing it about. Indeed, anal spasm, when caused by 
fissure of the anus, or any other disease of the mucous 
membrane of the inferior extremity of the rectum, is to a 
certain extent more or less of an impediment to restoration, 
and prevents the cause which produced it from being as 



40 ANAL FISSURE. 

speedily removed as it otherwise would be ; hence, although 
a mere effect, it may require treatment. My method in 
such cases is to treat both the cause and the effect at the 
same time. Whilst I consider it unpathological to make 
anal spasm in such cases the chief object of attention and 
treatment, as many do, I nevertheless insist upon it that the 
spasm must not be entirely overlooked and neglected in 
the treatment, for its reaction may have considerable in- 
fluence on the original focus of the disease. I, however, 
by no means agree with Mr. Malyn in the kind of treat- 
ment which is necessary to be adopted in such cases. I 
do not consider, as he does, that it is ever necessary to 
divide the sphincters of the anus, for I have never failed, 
in the worst cases, to easily and speedily overcome the 
spasm by the use of belladonna and proper dilatation ; 
at the same time using proper measures to subdue the 
inflammation, the congestion, and the morbid irritability of 
the parts which are the primary cause of the anal spasm. 
I am aware that Mr. Malyn says that in the aggravated 
form of anal spasm the introduction of a bougie is unscien- 
tific in principle and inapplicable in practice. — (Op. cit. p. 
340.) I, on the contrary, notwithstanding, do maintain that 
its proper use in such instances is both scientific in principle 
and highly applicable in practice, for I have successfully 
treated a number of just such cases. I would say in con- 
clusion, that the operation of Mr. Malyn in dividing the 
sphincter ani muscles with the knife, is unscientific in prin- 
ciple and abominable in practice ; and that it is like cut- 
ting the " Gordian knot" instead of untying it. 



CHAPTER SECOND. 



ANAL FISSURE. 



CHAPTER II. 

FISSURE OF THE ANUS. 

Section I. — Name. 

The term fissure is derived from the Latin fissura^a cleft, 
a slit, a chap, — from findo, to cleave, to slit, to chap. 

Fissure of the Anus — English. 

Fissura Ani — Latin. 

Fissure a VAnus — -French. 

Fissur des Afters — German. 
There is great disagreement among medical writers with 
regard to the precise application of the term fissure of the 
anus. Mr. Mayo includes under it breaches of surface of 
all forms, whether linear or oblong, located anywhere in the 
inferior extremity of the rectum, and about the anal orifice, 
either within or without, and whether irritable and painful 
or attended by anal spasm or not (Op. cit.). This is apply- 
ing to the term the most extensive application. M. Mon- 
tegre classes under the same general head, fissures attended 
by spasm, rhagades, and simple crevices or chapping of the 
muco-cutaneous tissue about the anus. He says, under 
the head, " Des crevasses, fissures ou rhagades a Vanus : " " Ces 
trois mots ont une meme signification. II s'agit toujours 
d'une .petite ulceration longitudinale, dont les varietes sont 
relatives seulement a la cause qui les a produites." — (Des 
Hemorroides, ou ^raite Analytique de toutes les afjections hemorrdi- 
dales. Nouvelle Edit, p. 51. Paris, 1819.) Some authorities 
consider the linear form of the ulcer and anal spasm as essen- 
tial to the disease, and regard them in the relation of cause 
and effect; one party of these believing the anal spasm to 
be the primary symptom, whilst the other party consider the 



44 ANAL FISSURE. 

fissure to be the primary disease. There are others again 
who go still further, and consider the anal spasm as the 
true, the real disease, and the fissure or linear ulcer as a 
mere secondary complication. 

The term fissure of the anus, as I have already shown in 
the previous chapter, has been incorrectly applied by many 
authors to a phenomenon which sometimes attends the 
second or advanced stage of anal fissure, but which does 
not in reality constitute it, but is a mere symptom or an 
effect of it — I mean anal spasm. I have also shown that 
others, equally incorrect, have included in the term every 
superficial lesion situated in the anal canal, and about the 
margin of the anal orifice, of whatever character, whether 
idiopathic or not. 

This term in its limited sense, or in its strict application, 
implies simply a superficial breach of surface, of a lineal or 
long and narrow shape, located on the mucous lining of 
the inferior extremity of the rectum ; or on the muco-cu- 
taneous coat about the anal orifice. The term, however, 
in its more extended sense is used to express those super- 
ficial ulcerations in which fissures sometimes terminate. 
Occasionally, too, superficial lesions are met with in this 
region, differing in form, yet having all the other character- 
istics peculiar to fissure ; these must be included in the term, 
inasmuch as the mere form of the ulcer is not of itself the 
pathognomonic sign of the disease. The characteristic form 
of lesions in the inferior extremity of the rectum is no doubt 
communicated to them by the irregularities of the mucous 
lining in this locality, disposed as it is into numerous rugae. 
I have myself particularly noticed, and it is worthy of ob- 
servation, that, in the lower portion of the rectum, and 
more especially about the anal orifice, where the radiated 
duplicatures of the mucous membrane and muco-cutaneous 
coat are longitudinal, the ulcers are, with scarcely an excep- 
tion, linear in form ; whereas in the middle and superior 



ANAL FISSURE. 45 

portion, where the folds are disposed transversely, they are 
almost always circular or oblong. But, as I have before re- 
marked, the true character or nature of the disease cannot 
be determined by the mere form alone of the lesion, be it 
linear, circular, or oblong. 

From these several considerations I conclude that the 
term fissure of the anus, which serves no purpose as a descrip- 
tive or a distinctive name, is not as good a one to designate 
this painful affection as might have been adopted ; but its 
use has now been so long sanctioned by authority, that I 
do not feel at liberty to venture upon the substitution of a 
newly created one. The term thus retained as a nosolo- 
gical distinction, should be strictly confined to superficial 
breaches of surface in the anal region, of a highly sensitive, 
irritable, or painful character, whether linear, oblong, or cir- 
cular, or whether attended by anal spasm or not. 

The talented and ingenious author, Mr. Curling, already 
quoted, very appropriately denominates fissure of the anus 
"Irritable Ulcer of the Rectum." This is what it really 
and truly is, regardless of its form. Mr. Curling objects 
to the term fissure, because it is so only in appearance, and 
not in reality. He says: "On examining the ulcer with- 
out distending the rectum, the lateral edges only being 
presented to view, the breach of surface has the appearance 
of a fissure — the term commonly given, but improperly, to 
this sore, which, though often originating in a rent, is 
obviously more than a mere cleft or fissure in the mucous 
membrane of the bowel." And again he says : " With 
the speculum, the longitudinal folds being stretched out, 
the ulcer can be fully exposed, and it is then clearly seen 
not to be a mere fissure, but a superficial sore." — (Op. cit. p. 6.) 

Mr. Ashton, in commenting upon the remarks of Mr. 
Curling, says : " Although in many instances when the sur- 
geon is first consulted, it (the fissure) may present the form 
of an oblong ulcer, yet I have no hesitation in saying the 



46 ANAL FISSURE. 

primary condition was essentially a fissure or crack of the 
mucous membrane." — (The Diseases, Injuries, and Malforma- 
tions of the Rectum and Anus. Third Edition, p. 45. London, 
i860.) 

I do not concur with Mr. Curling in the opinion that all 
lesions about the anus and in the anal canal, presenting a 
linear form and termed fissures, are only so in appearance 
and not in reality. That some such by long continuance 
become more extensive, degenerate into sores or ulcers, and 
lose their original form, is doubtless true ; but such are 
the exception, not the rule. As far as my experience 
extends, in the largest majority of cases of long standing 
which have come under my own observation, I have found 
the breaches of surface to be of a linear form ; they were 
doubtless of this shape originally, and they seemed to have 
maintained it. These cases were examined carefully with 
a speculum, and the ulcers did not only appear in the form 
of fissure previous to its use, but were by its use proved to 
be so in reality. Distention of the mucous membrane 
upon which they were located made no change in their 
form, from the lineal to the circular or oblong. 

Mr. Ouain may be said to object to the term fissure of 
the anus by implication, inasmuch as he does not use it to 
designate the disease so called, but treats of it under the 
head, " Painful Excoriations and Ulcers of the Skin and 
Mucous Membrane." — (Op. cit. p. 154.) 

Mr. Smith introduces the subject of fissure of the anus 
under the head, " Painful Ulcer of the Rectum!' From the 
fact of substituting this term for that of fissure of the anus, it 
is evident that he considers the latter not as appropriate as 
his own, the former. — (Hemorrhoids and Prolapsus of the 
Rectum. Third Edition, p. 1 24. London, 1 862.) 

It will be seen I have given three English authorities 
who repudiate the term fissure of the anus. 



ANAL FISSURE. 47 

Section II. — Physiology. 

It may be premised here that fissure of the anus is an 
idiopathic disease of the mucous membrane of the inferior 
portion of the rectum, or of the muco-cutaneous coat about 
the anal orifice ; and not a disease of the muscular coat or 
muscular fibres of the intestine, nor of the sphinctores ani 
muscles. It consists in an idiopathic breach of surface, as 
a superficial ulcer, an excoriation or abrasion, and, as a gen- 
eral rule, has a linear, or long and narrow form. The dis- 
ease is always attended by a peculiar kind of pain, of a 
sharp, lancinating, throbbing, burning, or smarting character, 
and sometimes, in the advanced stage, by a violent and 
arbitrary contraction of the sphincter or sphincters of the 
anus. The pain may, and often does occur in the act of de- 
fecation, but it most frequently comes on some time after 
the parts have been disturbed by this act, and irritated and 
excited by the passage of faecal matter, or vitiated and stim- 
ulating secretions. The fissure in this peculiar condition, 
being thus highly irritated and excited, communicates this 
irritation and this excitability to the muscular coat and to 
the sphinctores ani, and causes one or both of them to con- 
tract violently upon the highly sensitive sore of the mucous 
membrane within its grasp ; hence the additional or most 
exquisite pain which immediately follows this mechanical 
violence of grasping and compressing, and which lasts 
just as long as this exalted muscular constriction continues. 
The sphincter ani muscles are sympathetically impressed, 
or influenced by the morbid state of the fissure, — hence the 
spasm. 

I would mention here, and facts tend to warrant the con- 
clusion, that in some morbid conditions of the anus and 
anal region, whether induced by fissure or by some other 
cause, extreme sensibility of the nerves of the part, and 
spasmodic contraction of the anus, often co-exist as 



48 ANAL FISSURE. 

parts of the same disease. When the nerves are rendered 
morbidly sensitive by the irritation and inflammation 
existing in the part, the violent pressure made upon them, 
in this highly sensitive state, by the excessive or inordinate 
contraction of the muscular fibres of the sphincter ani, must 
of necessity give origin to additional and excessive sensa- 
tion. This, and the compression of the fissure by the same 
muscular fibres, are both causes of additional pain, by anal 
spasm. Any morbid sensibility of the mucous membrane 
of the inferior portion of the rectum disposes the muscular 
coat of the same to resist any distention, or extension, 
beyond its tonic contraction or quiescent state, or that state 
in which it is when not distended by fseces, gas, or any 
other foreign body. Neither will the sphincter ani muscles 
in this morbid condition of the parts admit of distention 
without the induction of agonizing pain. It is a question 
whether this arbitrary contraction of the sphincters of the 
anus would cause pain without a fissure, or any other dis- 
ease of the mucous membrane of the part, as in cases 
in which the spasmodic contraction is caused by disease in 
the genito-urinary organs, some distance removed from 
them. It certainly would, but by no means to the same 
extent, unless firm pressure or distention was made, and 
then upon the removal of which it would cease. When 
the pain attending the spasmodic contraction is very intense, 
it is an evidence that it is owing to a fissure, or to some 
other disease of the mucous membrane of the part, which, 
without even being violently compressed by the contraction 
of the muscular fibres of the sphincters of the anus, would be 
more or less painful, especially after having been excited 
by the passage of highly acrid and stimulating dejections. 

] . Sensibility of the terminal Outlets of the Body. The 
sensibility of all mucous membranes is greatest at the 
extremities or the outlets of the canals which they line. 
When this membrane in such locality is diseased from 



ANAL FISSURE. 49 

any cause, there is more or less pain experienced whenever 
the common function of the part is performed. The canal 
at this point sometimes contracts spasmodically on the ap- 
plication even of its own proper and natural contents, and 
offers more or less impediment to their passage. Indeed 
such disease of the mucous tissue always diminishes to a 
greater or less degree the canal it lines, and especially its 
terminal orifice, and makes any attempt to distend the same 
both difficult and painful. This is doubtless owing to the 
fact that the outlets of the body are supplied or endowed 
with a peculiar nervous influence which is obviously con- 
nected with their proper functions. 

With especial reference to the terminal outlet of the in- 
testinal canal and the disease in question, the direct cause of 
the extreme and agonizing pain is the result, to a great ex- 
tent, as before remarked, of the violent involuntary spas- 
modic contraction of the sphincters of the anus upon the 
already highly painful and sensitive ulcer, thus rendering it 
if possible still more exquisitely painful, as well as more or 
less preventing it from healing. This view of the subject 
is in accordance with the pathology of the disease, as well 
as with the physiological condition of both sphinctores ani 
muscles, whose involuntary contraction, both tonic and spas- 
modic, is entirely owing to the peculiar nervous endow- 
ment previously named, as the latest pathological and 
physiological researches tend so strongly to demonstrate. 

2. Tonic and Muscular Contraction of the Anal Sphincters. 
The sphinctores ani muscl.es may be said to display two kinds 
of contraction, the tonic and the muscular. The tonic con- 
traction is that property in virtue of which they constantly 
tend to resume their natural or quiescent state whenever 
the cause which distended them and which brought into 
play their muscular contraction is removed. The normal 
condition, then, of these two muscles is unconscious contrac- 
tion of their muscular fibres, and this contraction is increased 

4 



^O ANAL FISSURE. 

and rendered more effectual by the voluntary contraction 
of the levatores ani muscles. It is by the tonic contraction 
of the sphinctores ani that involuntary discharges of the 
feces are prevented. In the healthy and natural state of 
the parts, this contraction does not close the anus or anal 
canal with any great degree of tightness, for the finger, or a 
proper sized bougie, warmed and lubricated, may always be 
insinuated with ease. The internal sphincter, as a general 
rule, is found to be more firmly contracted than the exter- 
nal, but not sufficiently so to produce very hard pressure 
upon the hsemorrhoidal plexus, or upon the mucous mem- 
brane ; nor is it in turn strongly pressed upon by those 
fibres of the external sphincter which surround its neck. 

3. Tfe Influence of the Will vpon the Anal Sphincters. The 
two sphincter muscles of the anus are said to be under the 
control of the will, but this must be accepted in a limited 
sense, for they are by no means completely so, especially 
the sphincter internus. They stand in physiological func- 
tion between the involuntary and voluntary system of 
nerves, consequently an evacuation can often be voluntarily 
effected in concert with the action of the diaphragm and 
other abdominal muscles; but at other times they must 
necessarily obey the automatic movements of the organic 
functions of the intestines alone. 

The expansion or relaxation of the anal sphincters, 
especially the external, which precedes the expulsive effort, 
is, to a certain extent, an act of the will, a circumstance 
which makes the resistance of these muscles more easily over- 
come. Contraction of the same, however, is always invol- 
untary, and not at all under the control of the will. 

The supposition that a special nervous influence is neces- 
sary to govern the relaxation and contraction of the anus, 
has been entertained by several eminent physiologists. The 
ingenious and talented Italian, Professor Bellingeri, held this 
view, and endeavored to demonstrate it by experiment. 



ANAL FISSURE. 51 

In his experimental inquiry into the functions of the spinal 
marrow, he believes he has proved that the posterior col- 
umns of the spinal marrow give nerves to the external 
sphincter which endow it with the power of contraction, 
whilst branches from the anterior columns bestow upon it 
the faculty of relaxation. — (Experimenta Physiologica impedul- 
lam Spinalem. Lecta die 13 Junii, 1824. From Memorie delta 
Reale Accademia detle Scienze Di Torino XXX. Turin, 1826. 
Analyzed in the 'Journat des Progres des Sciences, &c. 'Tome I, 
p. 125. Paris, 1827). 

The result of the experiments of this learned but fanciful 
author, is by no means conclusive upon the point in question. 
Many important objections could be urged against his ex- 
periments ; and the invalidity too, of his deductions could 
be easily demonstrated, but this is not the proper place to 
do it. 

The fibres of the sphinctores ani muscles may be stimu- 
lated to action directly by the will ; or indirectly by reflex, 
irritation, the one action being voluntary and the other in- 
voluntary. The philosophy of reflex action in its relations 
to nervous phenomena is at the present time attracting great 
attention. To know that all morbid manifestations may be 
due to reflex influence is of the highest importance. This 
theory, when applied to the disease in question, appears in- 
deed most highly probable, for it would seem reasonable 
enough that any irritable or painful condition of that part 
of the mucous membrane of the rectum, or muco-cutane- 
ous coat about the anal orifice, within the immediate grasp 
of the anal sphincters, would, through the medium of reflex 
action, highly increase the intensity of the nervous influence 
which causes or stimulates this spasmodic contraction. 

It is stated by Mr. W. P. Alison that when any stimulus is 
applied to muscular fibres, either directly by the will, or in- 
directly by reflex irritation, the filaments which are directly 
stimulated are thrown into action, then contractions very 



52 ANAL FISSURE. 

generally and rapidly extend to many others in their vicini- 
ty, frequently to the whole muscle of which they form a 
part. But he considers the contractions of individual fibres 
to be feeble and of short duration. — {Cyclopedia of Anato??iy 
and Physiology. By R. B. fodd, M.D. Vol. /., p. 719. London. 

1836.) 

4. Nervous 'Endowment of the Rectum. The rectum is the 
only portion of the intestinal canal which receives addition- 
al nerves from the cerebro-spinal system ; consequently it is 
endowed with much greater sensibility, and subjected to a 
much greater number of influences, both healthy and mor- 
bid, than any other portions of the canal ; — hence its func- 
tions too are of a mixed character, partaking, in part, both 
of voluntary and involuntary motion. Were the rectum 
not thus suitably endowed with nerves like telegraphic wires, 
to put it in relation, or in communication with other organs, 
and enable it to receive and to respond to impressions made 
upon it, the organ would fail to fulfil its offices as such. 
But, as before remarked, the rectum, in addition to the or- 
ganic sensibility with which it is endowed in common with 
all parts of the intestinal canal, by nerves from the gangli- 
onic system, is also endowed with animal sensibility, by 
nerves from the cerebro-spinal system, the peculiar property 
of which is that kind of sensibility which we can plainly 
perceive and of which we are distinctly conscious. 

5. Hypertrophy of the External Sphincter Ani. The repeated 
and long-continued hyperaction of this muscle, consequent 
upon anal fissure, or from any other cause, ultimately tends 
to augment both its bulk and its strength, as well as it facili- 
tates its subsequent excitation of action. This is in con- 
formity with the general law, that the repeated exertion of 
living contractile parts is to increase them in size and in 
strength, which is doubtless owing to a greater flow of blood 
to them, and consequently with an increase of their nutri- 
tion. Ii the finger is introduced within the anus in such a 



ANAL FISSURE. 53 

case, the external sphincter, in particular, will be found so 
much altered in respect to size, that it will have more the 
feel of a thick cartilaginous ring than a band of soft fleshy 
fibres, and that this sometimes extends as far as the upper 
margin of the internal sphincter of the anus, several in- 
stances of which have come under my own observation, the 
result of long-continued anal fissure. 

This hypertrophy of the sphincters of the anus, purely 
the result of continued irritation or violent action, is strik- 
ingly evident in those who have for a length of time suf- 
fered from this affection, It is interesting in a physiologico- 
pathological point of view. 



CHAPTER THIRD. 



ETIOLOGY, 



CHAPTER III. 



ETIOLOGY. 



] . Constipation as a Cause of Anal Fissure. I have already 
shown in the first chapter that the ancients attributed fis- 
sures of the rectum and anus principally to constipation 
of the bowels, and to the desiccated condition of the ster- 
coraceous matters incident to such constipated state. Albu- 
casis and Paulus iEgineta especially impute them to these 
causes. It will be very readily perceived how constipation 
of the bowels, with its train of attending evils, — indura- 
tion of the faeces and the violent action of the expulsive 
muscles requisite for their evacuation, — maybe causes of anal 
fissure. Faecal matter in its natural state is consistent, soft, 
homogeneous and cohesive, but when unduly retained in 
the rectum, or colon, becomes hard, knotty, dry and friable, 
changes produced by the absorption of its fluids ; even in 
its normal condition, when retained but a short time beyond 
the usual period, it irritates the delicate mucous surface 
more or less ;. yet how much more irritating must it prove 
when its characters have become entirely altered by a 
lengthened stay in the bowels. It is an established fact 
that the absorbents of the rectum are very active ; conse- 
quently if faecal matter be retained in it beyond the usual 
period — twenty-four hours — it becomes consolidated and 
hard. For example, if a person who is in the habit of 
evacuating his bowels at a certain hour every morning, 



58 ANAL FISSURE. 

should, through the press of anxiety or business, or from 
any other cause, neglect to perform this highly important 
act, he will find that the stool which would have been 
natural and easy in the morning, will be difficult if not 
painful in the evening or next morning ; that the fseces will 
be hard and moulded in the bowel, and that the act of de- 
fecation will be attended with extra straining and with more 
or less pain, and often with blood. Should he suffer this 
condition to continue, anal fissure, or some other serious dis- 
ease of the rectum or anus, would most assuredly be the 
consequence. In many cases of constipation the difficulty 
occurs in the rectum, or colon itself, which in such cases 
seems to have lost its natural tone and action, suffering large 
accumulations of fseces to take place in its pouch, without 
manifesting any disposition or power to dislodge them ; and 
when finally expelled, to produce serious injury to the 
mucous membrane of the anal canal below, and often cause 
pains equal in severity to those of labor. Women are 
especially liable to this torpor and to these accumulations. 
In some cases of constipation, while the diaphragm and other 
abdominal muscles act with great energy, the anal sphincters 
remain more or less contracted, and yield but slowly and 
reluctantly, so that the indurated fseces contuse and abrade 
the surface of one or more points of the mucous membrane, 
which if they do not heal become converted into fissures. 
In such instances as contemplated above, the hard scybalous 
fseces being forced through the sphincters of the anus by the 
abdominal muscles, not only irritate or abrade the mucous 
membrane of the anal canal, but sometimes lacerate it, and 
thus directly lay the foundation of the disease in ques- 
tion. 

This disease is sometimes the result of inflammation and 
the attendant turgescence of the mucous membrane of the 
anal canal, by which the intestine becomes narrowed by the 
tumefaction of its lining coat, and thus forms an obstacle to 



ANAL FISSURE. 59 

the free egress of the faecal mass, which, if hard, is liable to 
abrade, lacerate, or rupture the mucous coat, in its highly 
delicate and friable condition. 

Anal fissure sometimes results from the excoriations pro- 
duced by the vitiated and irritating discharges in dysentery, 
diarrhoea, cholera, and other visceral diseases. 

The anus is liable to a species of chapping, resembling 
that of the lips in winter, which sometimes results in ex- 
tremely painful fissures. 

Obstinate fissures are sometimes produced in the fossa, 
between the two anal sphincters, by the lodgment of faecal 
matter or other foreign bodies, which here do not always 
find a ready and easy passage out, in consequence some- 
times of the contraction, either spasmodic or organic, of the 
external sphincter ani. More or less of such foreign matters 
constantly remaining in this pent up situation, become 
highly irritating in the intervals between the stools, and in 
this manner lay the foundation of some among the most 
painful fissures ; a number of such cases have come under 
my own observation, and will be reported hereafter under 
the proper head. 

Anal fissure is sometimes produced by a superficial 
excoriation or ulceration of the anus, similar to that 
so frequently observed upon the inside of the lips, the 
tongue, and other parts of the mouth. I have seen several 
severe cases of anal fissure produced by this kind of aph- 
thous ulceration in nursing mothers, and one in a young child; 
they were attended with extreme burning pain, and more 
or less anal spasm. [Vide Cases xix., xxiii., xxv.] In 
these cases the ulcerations of the anus were extemporaneous 
with similar ones of the mouth ; their coexistence at the 
same time, and the exact similarity of appearance between 
them, left but little doubt as to their identity. 

2. Severe Straining Efforts a Cause of Anal Fissure, This 
disease is sometimes caused by the violent straining efforts, 



60 ANAL FISSURE. 

consequent not only upon obstinate constipation, but upon 
those of dysentery, diarrhoea, stricture of the rectum or 
anus, whether spasmodic or permanent, and stone in the 
bladder. A laceration or rent of the mucous membrane 
lining the external sphincter takes place during such efforts. 
Such a rent being neglected, or suffered to continue without 
proper treatment, would sooner or later become highly irri- 
table, and ultimately produce that peculiar morbid condition 
of the parts which is characteristic of fissure of the anus. 
Several instances of anal fissure caused by the severe strain- 
ing efforts consequent upon the violent operation of drastic 
purgatives, have come under my own immediate observa- 
tion. Some of these cases will be found reported under the 
head, " Illustrative Cases" in the last chapter. 

A somewhat frequent cause of anal fissure is a deficiency 
in the secretion of the natural lubricants — the mucous and 
other secretions of the inferior extremity of the rectum, and 
about the anal orifice, which were intended by nature to fa- 
cilitate the passage of the excrement through the anal canal 
and anus. When this condition of the parts obtains, the 
mucous lining is often found quite friable, and consequently 
easily ruptured during the passage of indurated faeces, 

3. Anal Fissure from Mechanical Injuries. Under this head 
may be included those abrasions and lacerations which are 
produced by over-distention, or by the passage of hardened 
faeces in large masses, as before remarked ; or of a foreign 
body contained in the faeces, as well as those which follow 
surgical operations, and the careless and awkward use of 
the pipe of the enema syringe, the speculum ani, the rectal 
sound, or bougie. The disease is also sometimes the result 
of mechanical injury consequent upon very violent efforts 
made in parturition ; several cases of this character I have 
treated. It is sometimes the result of external violence 
communicated by falls, blows, &c, upon the anus, the 
nates, or the coccyx. A case of this kind came under my 



ANAL FISSURE. 6l 

own care. [ Vide Case xvi.] Two similar cases are re- 
ported by Mr. Rouse, as follows : — 

" Case I. — A gentleman, aged twenty-four, was riding a 
restive horse, when it suddenly bolted. He was thrown 
with some violence on the hind part of the saddle before 
he recovered his seat. He felt some pain about the anus 
at the time, and on changing his shirt he noticed a few 
drops of blood. For the next few days he experienced a 
slight burning pain during the evacuation of the bowels, 
and in about a week the characteristic pain of fissure was 
established. On examination being made, a small crack 
was perceived on the posterior surface of the sphincter ; it 
commenced about two lines within the anus, and extended 
upwards for about an inch. Various local means were tried 
without benefit, and an operation to be hereafter described 
was had recourse to with perfect success. 

" Case II. — A captain in the navy fell off a ladder, and 
came to the ground on his buttocks with considerable force. 
He did not observe any particular pain until he went to 
stool the following morning, when he experienced consider- 
able smarting, and noticed that he had passed a small 
amount of florid blood. About a week after the accident 
he applied for advice. He then, after every evacuation of 
the bowels, had pain which lasted for several hours. On 
examination, an ulcer was found on the posterior surface of 
the lining membrane of the sphincter; the edges were not 
indurated, and the surface was florid. An ointment con- 
taing mercury was applied twice a day, and in the course 
of a week a cure was effected." — (On Ulceration of the Lower 
Extremity of the Rectum; its Varieties, Diagnosis, and treatment. 
British Medical Journal. May \ith, i860, p. 356.) 

4. Anal Contraction as a Cause of Anal Fissure. Contraction 
of the anus or anal canal, either of an organic or of a spas- 
modic character, by opposing the free egress of the faeces, 
becomes a proeguminal cause of anal fissure ; in the 



62 ANAL FISSURE. 

former by disposing to rupture, and in the latter by con- 
tusion, excoriation, and abrasion of the mucous mem- 
brane. Congenital contraction of the anus may lay the 
foundation of this disease. — (Fide the author's work on the 
Congenital Malformations of the Rectum and Anus, p. 85. New 
Tork, i860.) 

Persons who have very large and extensive anal sphinc- 
ters, or very strong and powerful ones, are very liable to 
this affection, or predisposed to it. 

5. Anal Fissure from the Frequent use of Enemata. Some 
authorities are of opinion that it is in consequence of the 
frequent and indiscriminate use of lavements, so very com- 
mon on the continent of Europe, that anal fissure prevails 
so generally in that part of the country ; whilst in England 
and in the United States, where they are but seldom used, 
the disease is comparatively rare. The use of enemata, 
however, is daily on the increase in our own country, and 
so is anal fissure ; but I doubt whether this increased use of 
the former has anything whatever to do with this increase 
of the latter. 

6. Anal Fissure from Hemorrhoids and Condylomata. A very 
frequent predisposing cause and complication of this disease 
are hemorrhoidal tumors ; and when this is the case, the fis- 
sure will often be found between two of them. (Fig. 1 .) 
Haemorrhoids, by their presence in the anal canal, lessen its 
calibre, and in the act of defecation are first extruded and 
then. separated, during which process the delicate mucous 
lining is, by the forcible passage of hardened faeces, rup- 
tured. Condylomata, or excrescences of the anus, the result 
of chronic inflammation or irritation, are quite a frequent 
cause of anal fissure. They produce the disease by narrow- 
ing the anal orifice, becoming ulcerated at their base, and by 
the constant irritation they excite in the parts. I would ob- 
serve here that these condylomata or anal excrescences are 
at the present day too often confounded with true hsemor- 



ANAL FISSURE. 



63 



rhoids. This is an error that needs correction, for they are 
not of a hsemorrhoidal character. I have most always found 
anal fissure complicated with condylomata, having seen but 
few cases that were not accompanied by one or more of them. 




Fig. 1. 

7. Anal Fissure from Cutaneous Affections. Fissure of the 
anus is not unfrequently the result of a local variety of one or 
the other of the following cutaneous diseases : — Prurigo ^Ec- 
zema, Psoriasis, and Herpes. A thickening of the mucous 
membrane and muco-cutaneous coat of the terminal por- 
tion of the rectum takes place in one or the other of those 
affections, causing deep cracks or fissures, and exciting^viti- 
ated and acrid discharges, so that ultimately, if not relieved 
early, that morbid condition of the part takes place which is 
characteristic of anal fissure. 



64 ANAL FISSURE. 

8. Fenereal Origin of Anal Fissure. This disease may 
arise from the direct application of the venereal poison to 
the margin of the anus, as in " Unnatural Congress;" or a 
flow of it may take place from the genital organs to the 
anus. Females especially are very obnoxious to it from the 
circumstance that the vaginal discharges can so readily flow 
over parts of the anus. Or syphilitic fissure of the anus 
may be consecutive to disease in the genital organs, and 
then coexist with other secondary symptoms. 

9. Can Anal Fissure be produced Artificially ? M. Velpeau is 
of opinion that this disease cannot be produced artificially. 
This, however, is an error, for I myself have witnessed several 
cases to the contrary. In the removal of hsemorrhoidal 
tumors by the application of the nitric acid, or the fluid acid 
nitrate of mercury, if not very careful, sometimes a drop, or 
even less, may come in contact with the mucous membrane 
lining the external sphincter, and produce a small superficial 
ulcer, which in some instances becomes afterwards highly 
sensitive and irritable, and causes similar suffering precisely 
to that of anal fissure, and indeed constitutes this veritable 
disease. [Vide Case xv.] The same disease sometimes 
follows the excision of hsemorrhoidal tumors, either by the 
knife or the ligature, when a small ulcer is left from the 
operation, as I have on several occasions witnessed. [Vide 
Case xxvi.] Mr. Curling names one or two cases precisely 
of this nature. " One of the most painful ulcers," says Mr. 
Curling, " I have had to treat occurred, I was informed, 
after the excision of a small pile. In another case in which 
I removed a large pile by ligature, the patient, a gentleman, 
neglected my injunction to keep at rest afterwards. He 
returned too soon to active business, and an irritable sore 
was the consequence. I have also met with one which 
occurred after the removal of an internal pile by the acid 
nitrate of mercury in a lady of irritable constitution." — (Op. 
cit, p. 8.) 



ANAL FISSURE. 65 

1 o. Are the Causes of Anal Fissure obscure ? M. Boyer says 
that the causes of this disease are very obscure ; that he had 
observed among many of the patients he treated, it had 
been preceded by a hsemorrhoidal swelling; and that 
among some of these cases haemorrhoids had been of long 
standing. Now, in my opinion, the causes of anal fissure, 
as a general rule, are not obscure, as I have abundantly 
shown; take for example haemorrhoids as a cause. I am 
therefore surprised that M. Boyer, -with his extensive know- 
ledge and experience on the subject, should have made such 
an assertion. The truth is that all superficial lesions, es- 
pecially those of a linear shape, located on the mucous 
membrane lining both sphincters of the anus, are liable 
sooner or later of becoming so sensitive and irritable, from 
some of the numerous causes already enumerated, as to 
produce that morbid state of the parts which I term anal 
fissure, which is nothing more nor less than a highly sensi- 
tive and irritable ulcer, located in the inferior extremity of 
the rectum, and sometimes communicating its irritability to 
one or both sphincters of the anus, inducing in one or both 
spasmodic contraction of their muscular fibres. 

I will admit that the disease, in many instances, is so 
gradually developed, that it is difficult to assign it to its 
true and legitimate cause. Instances will sometimes be met 
with in which we will not be able to discover any probable 
or assignable cause. 

I would here remark in conclusion, that many of the 
causes of anal fissure which I have enumerated, it is true, 
produce other abrasions, excoriations, or ulcerations about 
the orifice and canal of the anus, which cannot for obvious 
reasons be termed anal fissure ; consequently care must be 
taken not to confound diseases alike in their cause and ap- 
pearance, yet very different in their symptoms and in their 
treatment. 

1 1. Who are the most Obnoxious to Anal Fissure ? It may be 

5 



66 



ANAL FISSURE. 



said, so far as temperaments are concerned, that the nervous, 
bilious, and the leucophlegmatic, are peculiarly susceptible 
of diseases of the mucous membrane of the rectum. Anal 
fissure is an affection that does not seem confined to any 
period of life, but it rarely exists until after puberty. It 
most commonly occurs between the ages of eighteen and 
fifty ; but I will presently show, contrary to the opinion of 
MM. Boyer, Velpeau, and some other eminent surgeons, 
that children are sometimes the subjects of it. I have my- 
self observed several marked and unmistakable cases in my 
own practice. [Vide Cases v., x., xix.] According to 
the experience of M. Trousseau at the Hospital Neckar in 
Paris, infants, even during suckling, are liable to this most 
distressing affection as well as adults. M. Duclos reports 
two highly interesting cases which came under the immedi- 
ate practice of M. Trousseau. These cases will be found 
reported in full in the chapter on the treatment of Anal Fis- 
sure. 

Mr. Miller says that fissure of the anus has been observed 
in children at the breast. — {Practice, of Surgery, p. 380. 
Edinburgh, 1852.) 

" Children, as we have observed," says M. Blandin, " and 
as it is clear, are not exempt from anal fissure, especially that 
form of it which is caused by a venereal taint ; and that 
which is caused by blows or other violence exercised upon 
the anus." — (hoc. cit!) 

This disease is met with in children whose constitution is 
feeble, and who have derangement of the digestive func- 
tions, and who either suffer from obstinate constipation of 
the bowels, or who have frequent diarrhoea; and in those 
who without the influence of these circumstances are badly 
cared for, and imperfectly attended to. The disease in 
children, as in adults, is caused by the straining efforts re- 
sulting from constipation of the bowels, and producing a 
superficial rent of the mucous membrane which lines the 



ANAL FISSURE. 67 

sphincter ani ; and in diarrhoea from the irritation and ery- 
thema of the anus which attend that disease. It sometimes 
occurs in children who are suffering from aphthse. 

The disease in its worst form, or spasmodic stage, does 
not as a general rule affect very aged persons, for in them 
the contractile power of the sphincters of the anus is gene- 
rally, to a greater or less degree, diminished. 

It is an affection common to both sexes, but women are 
certainly the most obnoxious to it, especially those who have 
borne children ; and often occurring in nursing mothers who 
are subject to aphthse. The principal causes in females, 
however, are doubtless a want of proper exercise and 
obstinate constipation of the bowels ; the first a predisposing 
and the last an exciting cause. Women, both from habit 
as well as from the usages of society, are sedentary, and in 
them constipation of the bowels generally prevails, caused 
in part by habitually neglecting the calls of nature, which 
they can with greater impunity do than men, in consequence 
of the greater amplitude of the pelvic cavity, but which 
sooner or later lays the foundation of the most serious mis- 
chief to some one or more of the important viscera of this 
cavity. 

Men of literary pursuits, or those closely engaged in 
study, as students; or employed at the desk or counter, as 
clerks, accountants, and salesmen ; or those confined to seats, 
as tailors, shoemakers, &c, are all liable to suffer from con- 
fined bowels. The want of bodily exercise generally les- 
sens the demand for food, weakens the digestive organs, and 
indigestion and constipation are almost a necessary conse- 
quence. 



CHAPTER FOURTH. 



CLASSIFICATION AND DESCRIPTION OF ANAL 

FISSURE. 



CHAPTER IV. 

CLASSIFICATION AND DESCRIPTION OF AN/AL FISSURE. 

Section I. — The Seat, and the Anatomical and Pathological Charac- 
ters of Anal Fissure. 

i . Seat. To a superficial observer it might seem super- 
fluous to speak of the seat of anal fissure, since the term it- 
self implies the locality of the disease, and to such it might 
also seem of no importance to distinguish and to describe it 
in accordance with its position. It will be perceived, how- 
ever, that it is important that the exact locality of the fissure 
should be pointed out, not only for the purpose of showing 
the great difference in the ulcer arising from its position 
within and without the anal orifice, but also to prevent 
confounding affections essentially alike in cause, but 
entirely different in nature and in symptoms, and requiring 
different modifications of treatment. Some authorities 
attach no therapeutical value whatever to such distinction. 
MM. Blandin and Dupuytren, however, acknowledge the 
importance of it. M. Blandin himself divides anal fissures 
into three divisions, as follows : — 

" l. Les fissures inferieures au sphincter. 

" 2. Les fissures superieures au sphincter de l'anus. 

"3. Les fissures a l'anus qui sont placees au niveau du 
sphincter." — (Op. cit.) 

2. Classification. I will, for the better elucidation of the 
subject, point out the different localities, in the inferior ex- 
tremity of the rectum, which fissures are found to occupy, 
as well as describe the different character they assume in 
each of such positions. They may therefore be distinguish- 



72 ANAL FISSURE. 

ed into four classes, according to their locality; believing 
this to be both a natural and a useful distinction. 

First Class. These are the fissures that are situated on the 
outside of the anal orifice, and immediately beyond the 
grasp of the external sphincter ani, and affect only the integu- 
ment, or the muco-cutaneous tissue. They often scarcely 
exceed four or five lines in length, and occupy the grooves 
between the duplicatures of the fine and delicate skin 
about the verge of the anus, and may be readily seen by- 
separating those folds. They sometimes appear in the form 
of excoriations or abrasions, consisting merely in the removal 
of the epithelium ; or in the form of narrow chaps, or oval 
or circular ulcers, having a red, but more frequently a yel- 
low or ash-colored base. They frequently penetrate through 
the epidermis, rete mucosum, and sometimes through the 
true skin, and are often attended by a slight oozing of a 
sub-acid discharge, and are very similar in appearance to 
those fissures or cracks that occur on the lips and angles of 
the mouth in some persons affected with herpetic com- 
plaints. The fissures of this locality, as a general rule, do 
not affect the external sphincter, so as to induce spasmodic 
contraction of that muscle, not being immediately within 
its grasp. Cases, however, of fissures in this locality do 
sometimes occur in which there will be violent spasmodic 
contraction of the external sphincter. Several such cases 
have fallen under my own observation. 

The fissures of this locality are always, however, attended 
with more or less intense smarting and burning pain, either 
while at stool, or some time afterward, and only occasionally 
by sympathetic spasm of the anus ; consequently they are 
justly entitled to the appellation, anal fissure, ox exquisitely ir- 
ritable ulcers of the anus. It must be distinctly understood, how- 
ever, that many of the abrasions, excoriations, and super- 
ficial ulcers of this region, produce nothing but an irrita- 
tion or soreness of the parts like that caused by a common 



ANAL FISSURE. 73 

sore, or like that caused by chafing or galling. Any and all 
such deserve not the appellation, fissure of the anus. 

Second Class. The fissures which belong to this class are 
situated immediately within the anal orifice, and affect the 
mucous membrane lining the sphincter externus, and are 
situated opposite to or on a level with this muscle. They 
are considered by some of the most able authorities to be 
the only true and genuine fissures. In these cases the in- 
ferior extremity of the fissure may be brought in sight and 
examined, by causing the patient to make expulsive efforts 
as if at stool ; or by forcibly divaricating the nates and the 
anal orifice with the hands and fingers, when the lower end 
of the ulcer will be exposed to view. In order, however, 
to obtain a complete view of the whole fissure, the anal 
speculum must be used, which, by rendering the mucous 
membrane tense, a vivid red line with a sharply defined 
edge, or a very narrow slit with redden margins will be ob- 
served. This fissure is more frequently found at the pos- 
terior part of the anal canal, or posterior surface of the 
sphincter ani, than at any other locality ; less frequently on 
the sides, and still less at the anterior part of the anal canal, 
or perinseal surface of the sphincter. About two-thirds of 
the cases I have treated, I have found the fissure situated on 
the posterior surface of the external sphincter. The next 
point in frequency, so far as my experience goes, is on the 
sides of the anal canal. I do not think I have treated 
twenty cases in which the fissure was situated on the peri- 
nseal surface of the sphincter muscle. The position of the 
fissure, however, varies considerably, so does also the degree 
of the morbid alteration. It most generally begins about 
a line above the margin of the anus, and prolongs itself in a 
vertical direction, following one or the other of the furrows 
between the folds or columns of the mucous lining of the 
anal canal ; and varying in length from the third of an inch 
to one inch and a third. It is rare that more than one 



74 ANAL FISSURE. 

fissure exists at the same time ; yet I have seen as many as 
three and four very small ones existing simultaneously. In 
some instances, in the early stage of the disease, one or two 
bright red granulations sometimes sprout up in the fissure, 
and give rise to more or less haemorrhage at each evacuation 
of the bowels. If the disease is suffered to go on without 
any active treatment, the appearance of the fissure soon 
changes. When recent, its edges are soft and pliant, and 
but little raised ; but in the exact ratio in which the ulcer 
becomes chronic from long continuance, its edges become 
hard and elevated, or everted, changes which depend upon 
the interstitial deposition of adventitious matter from the in- 
flamed capillaries. The surface of the ulcer itself looks 
pale, like any other indolent sore, and from which there is a 
little secretion, and sometimes at stool a little blood and 
mucus are passed. The mucous membrane surrounding 
the fissure also undergoes changes; for a while at first it 
retains its natural color, but when the disease is of long 
standing it often presents an erysipelatous hue ; and then 
again it assumes a livid aspect, and becomes soft. 

This solution of continuity never extends in depth fur- 
ther than to the muscular tissue. In the majority of cases 
it does not even extend through the mucous membrane ; 
but cases do occur in which the ulceration not only extends 
through the mucous, but also through the submucous 
cellular tissue which unites the mucous to the mus- 
cular coat. M. Merat, if I understand him, intimates 
that it sometimes does attack the muscular tissue. He 
says : — " Le tissu affecte est la membrane muqueuse, mais 
il n'est pas rare que l'ulceration depasse son niveau, et gagne 
la portion musculaire de l'intestin." — (Dictionnaire des Sciences 
Medicates. Tome XF. Art. Fissure, p. 544. Paris, 1816.) 
MM. Dupuytren and Blandin both declare that the ulcer 
rarely ever extends even through the mucous membrane. 
M. Dupuytren says : — " Cette ulceration n'atteint que tres- 



ANAL FISSURE. 75 

rarement toute Pepaisseur de la membrane muqueuse." — 
(Op. cit. p. 151.) M. Blandin says: — "Cette ulceration 
n'atteint que rarement toute Pepaisseur de la membrane 
muqueuse." — (Op. cit. p. 156.) 

I have seen two cases in which the ulceration had ex- 
tended itself completely through the mucous and submu- 
cous cellular tissue to the muscular coat. Mr. Curling re- 
lates a case in which he could distinctly perceive the fibres 
of the sphincter ani forming the bottom of the ulcer. — (Op. 
cit. p. 1 1 .) I have never seen the record of any case in 
which the fissure is said to have completely invaded the 
muscular coat. 

The fissures of this class are, as a general rule, the most 
painful and the most serious of any others met with. They 
are most always attended with sympathetic spasmodic con- 
traction of one or both anal sphincters; and even when un- 
attended by violent anal spasm, they are of the most exqui- 
sitely painful nature. 

Third Class. The ulcers or fissures of this class are situ- 
ated above the sphincter externus, in the middle region of 
the anal canal, in the small space or fossa which exists 
there, between the two sphincters. They can only be seen 
by the use of the speculum ani; but may easily be detected 
by the finger in ano. These fissures are generally of an ob- 
long or circular form, and are but seldom linear (Fig. 2) ; 
they vary in size from a half split pea to that of a silver 
dime, or to the end of the index finger. In cases of long 
standing the edges of the ulcer are indurated, but the centre 
generally remains soft and of a grayish or bright red color, 
and from which a little purulent or sanio-purulent matter 
passes at each evacuation of the bowels. These ulcers, ac- 
cording to my experience, are generally situated on the 
lateral parts of the canal, and but seldom on the posterior 
or anterior parts. On a digital examination the sensation 
which the ulcer communicates to the finger is that of an ex- 



-6 ANAL FISSURE. 

cavation. This fissure/as a general rule, does not induce 
sympathetic spasmodic contraction of the anal sphincters ; 
indeed anal spasm does but seldom accompany it, but as the 
ulcer is touched or pressed upon by the finger, the muscle 
instantly grasps it firmly. The pain of this kind of fissure 




Fig. 2. 



is most intensely sharp and burning, commencing either 
while at stool or a short time after, and continuing for sev- 
eral hours, often amounting almost to agony, whether being 
attended by anal spasm or not. In consequence of the ab- 



ANAL FISSURE. 77 

sence generally of spasmodic contraction of the anal sphinc- 
ters, an examination may be made, as well as the treatment 
carried out with but little suffering to the patient, obviating 
thereby the necessity generally of the use of anaesthetics ; 
indeed the external sphincter, instead of being in a state of 
spasm, is often found quite relaxed. It is in this locality 
that the excavated ulcer of the late and eminent Mr. Colles 
is situated, and which he has described in the Dublin Hos- 
pital Reports. Vol. F.p. 155. Dublin, 1830. Several cases of 
this peculiar species of fissure, or obstinate ulcer between 
the sphincters, have come under my own observation. 
[Vide Cases vin., ix., xxix.] An ulcer not in the form 
of fissure, but oval or circular, and attended with all the 
usual characteristics of fissure, is mentioned by Sir. Benj. 
Brodie in a lecture on the diseases of the rectum, in the 
London Medical and Surgical Journal, Vol. V. p. 286. London, 
1834. I rather incline to the opinion that the ulcer of Mr- 
Colles and that of Sir Benj. Brodie are identical. Mr. Quain 
also mentions the same kind of ulcer. — (Op. cit. p. 162, case 

53-) 

The ulcer mentioned and described by Mr. Colles is 
generally situated in the fossa between the two anal sphinc- 
ters ; it is sometimes, however, situated a little higher up or 
lower down, and on a level with one or the other of the sphinc- 
ters. The form of the ulcer, instead of being linear as in 
the second class, is generally oblong or circular. It is ex- 
cavated, having raised edges and a deep soft bottom, of a 
grayish appearance, and attended by a considerable purulent 
discharge. This kind of fissure is generally accompanied 
by enlargement of the hemorrhoidal veins ; or by a con* 
siderable tumefaction about the verge of the anus. 

Fourth Class. These are the fissures which are situated on 
the mucous membrane lining the sphincter internus, and a short 
distance above this muscle. They can only be seen by the 
use of the speculum ani. These fissures are somewhat rare, or 



^g ANAL FISSURE. 

perhaps are overlooked. (Fig. 3.) They do not produce the 
extreme suffering which those of the second and third class do. 
The pain is not so sharp and burning, but more of a dull, 
heavy ache or bearing down, and lasts for several hours after 
an evacuation of the bowels. It is sometimes attended 
with spasmodic contraction of one or both of the sphincters 
of the anus, but this is not frequent. Ulcers in this situa- 




Fig. 3. 

tion cause considerable sympathetic irritation at the neck of 
the bladder, there being often a constant desire to pass urine 
with but little ability to do so, which is sometimes very 
troublesome, and a serious addition to the other sufferings of 
the patient. I have treated two cases of this kind. 

A fissure in this locality is sometimes most difficult to 
detect. 



ANAL FISSURE. 79 



Section II. — The Symptoms and Signs of Anal Fissure. 

The evidences of this disease are of two kinds, — namely, 
those which have reference to the disturbance of the parts 
both immediately and remotely concerned, being manifested 
by numerous and various symptoms ; and those which relate 
to the appearance of the parts directly involved. 

The most striking feature in the nature of anal fissure is 
the great disproportion which exists between the extent of 
the solution of continuity, and the intense suffering it oc- 
casions. Indeed the very great distress which is experienced, 
and the nervous anxiety which is often manifested, even by 
firm-minded persons, are surprising when the insignificant 
amount of the local malady is taken into consideration. 

1. Symptoms. The characteristic or essential symptoms of 
anal fissure, are a severe smarting or burning pain in the 
anus or anal canal, occurring during the act of defecation, 
or a short time after, attended sometimes with a sympathet- 
ic spasmodic contraction of one or both sphincters of the 
anus. The exacerbation of pain does not precede the evac- 
uation, as it generally does in inflammatory affections of the 
anus, but most commonly follows, after an interval of a itw 
minutes. 

The symptoms of this disease at its inception are not very 
severe, being for a longer or shorter period merely an un- 
easy sensation, consisting of an itching, pricking, slight 
smarting, or feeling of heat in a certain point in the circum- 
ference of the anus, and occurring only during the evacua- 
tion of the bowels, and for a {ew minutes after. As the 
disease advances this uneasy sensation gradually increases, 
and sooner or later gives place to a most severe burning, 
lancinating, or throbbing pain. The sensation of burning at 
the time of stooling sometimes exists to such a degree that 
it produces the most inconceivable anguish, but which in 



80 ANAL FISSURE. 

some instances is almost entirely relieved on the completion 
of the act of defecation ; whilst in others it is only to be re- 
newed soon afterwards, with, if possible, greater violence. 
The pain occupies a circumscribed space about the margin 
of the anus, and is often attended, when very severe, by a 
pulsation of the vessels similar to that which generally 
accompanies phlegmonous inflammation. The attack of 
local pain being at an end the patient feels perfectly well, 
and apparently would continue so, were it not for the dis- 
turbing or the distressing effect of the passage of the fecal 
matter again. In consequence of this, some patients manage 
to curtail the number of their evacuations, and others reduce 
the quantity of food to a very small amount for the same 
purpose, and to avoid increasing the fecal mass, or having 
large evacuations, being well aware that such cause addi- 
tional suffering. According to my observation the largest 
proportion of patients, however, suffer none at all whilst 
evacuating their bowels; or if they do suffer, it is so trifling 
as not to attract their serious attention ; but in the course 
of ten, twenty, or thirty minutes, or one or two hours after 
the evacuation, they experience the most intense smarting, 
burning, or lancinating pains, which are often accompanied 
with violent spasmodic contraction of one or both anal 
sphincters. The degree of contraction, however, is by no 
means in proportion to the amount of suffering. As the 
disease progresses the pain, if possible, becomes daily more 
aggravated after each evacuation, often conveying to the 
patient the sensation of scalding, or of a red-hot iron being 
thrust into the anus, and gradually increasing in intensity 
until it has arrived at its maximum, when the patient 
suffers the most excruciating torture, sometimes bringing on 
a feeling of syncope, or a threatening of convulsions. These 
sufferings continue unmitigated for a length of time, vary- 
ing in different cases from two to twelve hours, or even 
longer, when they either gradually or suddenly abate and 



ANAL FISSURE. 8l 

leave the patient in perfect ease, as it were, until a renewal 
of the necessity for the passage of fseces causes a return of 
the sufferings, the interim being spent by the patient " in 
that delicious calm," says Mr. Calvert, " which usually follows 
violent suffering, and which may be termed, not inaptly, the 
very luxury of sensation."— (Op. cit. p. 213.) 

In some few instances, provided the patients have a daily 
evacuation, the pain lasts from one stool to another, requir- 
ing them to maintain the recumbent posture almost all the 
time. Others who daily evacuate their bowels, do so just 
on retiring to bed, as the horizontal posture affords relief 
generally, and they wish to be enabled on the morrow to 
attend to business during the day. Some, however, cannot 
maintain the horizontal posture without the most terrible 
suffering, being compelled to sleep in a sitting posture, on 
a hard seat. A remarkable case of this kind came under 
my own observation. [Vide Case xx.] Some patients 
are enabled to walk about, sit down, or attend to their busi- 
ness during the interval between the attacks, but others 
again are compelled to keep their beds. If the disease is 
not promptly arrested by treatment, it will progress. The 
pains will become continuous, and much more easily excited, 
especially in irritable habits or constitutions, when they may 
be produced by the slightest causes — such as any sudden 
movement of the body, as walking, coughing, sneezing, 
blowing the nose, singing, loud speaking, urinating, strong 
passions of the mind; or any cause whatever that produces 
local or general excitement. 

Flatulence is a symptom that generally attends severe cases 
of anal fissure, and it is very troublesome, as well as painful, 
the disengagement of gas being almost certain to bring on a 
paroxysm of pain; and when it is impossible to pass it, as is 
sometimes the case on account of anal spasm, it is a source 
of great discomfort and annoyance, by producing a continu- 
ous kind of colic, and a bearing-down feeling. I do not 

6 



82 ANAL FISSURE. 

think I ever saw a severe case in which there was not more 
or less flatus present. M. Boyer mentions the case of a 
lady, one of his patients, who was tormented with a contin- 
ued desire and impossibility of passing flatus. She was 
compelled to wear continually an elastic canula in her bow- 
el, so as to let out the gas whenever it reached the tube in 
ano. I have frequently adopted the same expedient, to the 
very great comfort of the patient, in cases in which there 
was violent spasm of the anus. 

Any excess in eating or in drinking will aggravate the 
pains. In women the presence of the catamenia increases 
their suffering. The pain is always at once excited by the 
introduction into the anus of any foreign body, — such as 
the pipe of the enema syringe, &c, and if the attempt be 
made to pass up the finger, it will not only occasion more 
or less suffering, but the finger will be grasped powerfully 
by the sphincter muscle. In some cases lancinating pains 
extend to the bladder in the male, and to the uterus in the 
female, and in both sexes to the hypogastric region. In oc- 
casional cases of anal fissure the pain assumes a periodical 
character, depending upon some peculiar state of the con- 
stitution. 

In this disease, as before observed, the bowels become 
obstinately constipated, and in some instances evacuation 
takes place only once in every eight or ten days, unless pur- 
gatives or enemata are employed. Indeed the very nature 
of the disease leads to constipation. Such is the dread of 
having a stool that most patients postpone the act of defeca- 
tion as long as possible, some for two, three, four and even 
eight days, during which they are generally comparatively 
free from pain and nearly all expression of suffering subsides. 
So complete is the manifestation of health, that it would 
astonish a person ignorant of the nature of the disease, to be 
assured that as soon as defecation takes place the disease in 
all its violence would be renewed The affection is neither 



ANAL FISSURE. 83 

retarded nor diminished in the least by this suspension of 
defecation, but on the contrary its progress is unremitting ; 
and both the violence of the spasmodic contraction and the 
severity of the pain are, as it were, regenerated with an in- 
crease of intensity, proportioned to the duration of time 
during which they had been suspended by the absence of 
defecation. The additional suffering caused by the suspen- 
sion of defecation may be explained by the fact that an ac- 
cumulation of fseces taking place for several days in the 
bowel, becomes exceedingly hard, dry, and irritating; and 
when at length the rectum contracts to expel this indurated 
mass, its passage tears open afresh the fissure, and contuses, 
excoriates, and irritates the whole anal canal, — hence the 
anal sphincters, being highly stimulated and irritated by this 
increased pain, contract spasmodically ; and in this manner 
a contention is set up between the anal sphincters on the 
one part and the muscular walls of the intestine on the 
other, aided by the abdominal muscles. In some of these 
cases the efforts to evacuate the bowels are so violent and 
so prolonged, that respiration is sometimes suspended ; the 
face becomes injected and purple, and the blood appears 
ready to start through the skin. Patients for a long time, 
even after they have been cured of this disease, have a dread 
or a horror of stooling. 

In the severe cases, the patients, as a general rule, seem 
at a loss to find words sufficiently expressive to depict their 
sufferings, and they always speak of them in the superlative 
degree. They will compare the pain to that occasioned by 
a red-hot iron thrust into the bowel ; or by scalding water 
or molten lead thrown into the intestine ; or to a sharp knife 
run into the anus ; or to tearing or lacerating the margin 
of the anus. Females will often tell us that the pain is more 
severe and more intolerable than the pains of labor. The 
pain and suffering often give rise to loud expressions of 
agony, even in some of the most determined and resolute. 



84 ANAL FISSURE. 

When this disease is severe and of long duration, the pa- 
tients sometimes fall into a remarkable state of melancholy 
and extreme nervous susceptibility. In order to avoid 
stooling, they eat but little ; their digestion is impaired, and 
they gradually become emaciated and icteric; their counte- 
nance is expressive of pain, and they have the general ap- 
pearance of those suffering from serious organic disease. 
Such patients too, although they may have possessed the most 
happy, the most amiable and most even temper, or disposi- 
tion, gradually lose it, and become petulent, peevish, crab- 
bed, snappish, and unamiable. 

2. Interval of I'ime between the act of Defecation and the Ac 'ces- 
sion of the Pain. A remarkable circumstance in the nature 
of this singular disease, is the distinct lapse of time which 
takes place between the cessation of the act of defecation 
and the accession of the pain, in all those who suffer most 
after this act. There is, however, no certainty with regard 
to the exact time after, when the pain will come on. It 
may come on immediately after the excretion of the faeces, 
ten minutes after, half an hour, one or two hours, or even 
four hours after, according to some authorities. The cir- 
cumstance of this distinct interval of time, whether of long- 
er or of shorter duration, is nevertheless so certain and so 
uniform in these particular cases that it might be considered 
as the pathognomonic sign of this disease. " There is one 
symptom," says Mr. Colles, " that will better explain the 
nature of this disease, than even an examination through 
the rectum, and it is so constant and so obvious, that I 
wonder very much it has escaped writers on the subject, — 
it is, that there is always a distinct interval of time, from ten 
minutes to an hour or more, between the passage of the 
fseces and the occurrence of the pain." — (Op. cit. p. 279.) 
Mr. Ouain, when speaking on the same subject, also says: 
" It is remarkable that in no small proportion of cases, it is 
only after the lapse of some time from the act of defecation 



ANAL FISSURE. 85 

that the pain begins. The interval that elapses between 
the evacuation and the occurrence of the pain, varies from 
about ten minutes to half an hour, or even two hours. I 
cannot explain at all satisfactorily why an interval of time 
elapses between the application of the exciting cause and 
its effect ; nor can I account for the variations in its length." 
— (Op. cit. p. 169) 

The distinguished Professor Dr. Van Buren of our city, 
after quoting what Mr. Quain has said upon this subject, 
attempts to give an explanation of this phenomenon. He 
says : " To me it seems plain that the dilatation, to which 
the orifice of the anus is subjected by the extrusion of the 
fseces during the act of defecation, is sufficient to prevent the 
fibres of the sphincter muscle from resuming their full tonic 
contractility, for a short interval, and that the length of the 
interval depends entirely upon the size and hardness of the 
mass extruded, and the amount of stretching to which the 
orifice has been subjected." — (The American Medical Times. 
Vol. Fill. />. 218. New Tori, 1864.) 

In my opinion, the Professor has failed in the above to 
give a true, a rational, or a satisfactory explanation of this 
phenomenon. According to his hypothesis, both the inter- 
val of time and its length depend entirely upon the size and 
the solidity of the fsecal mass, and upon the amount of 
stretching to which the anal orifice has been subjected by 
such an evacuation. Now a soft or a fluid dejection is fatal 
to this theory, inasmuch as a fluid stool, for instance, is 
effected with the very slightest dilatation of the anal orifice, 
and with no stretching whatever, in the sense in which that 
word is used in the above ; so small indeed is the amount of 
dilatation which occurs during such an evacuation, that it is 
scarcely perceptible, consequently the interval following it 
should be so brief that it should occur in a moment after. 
But does it do so? Never. A fluid evacuation, effected 
without a particle of stretching of the anal orifice, neither 



86 ANAL FISSURE. 

obliterates nor shortens the interval, but rather lengthens it. 
This faet I myself have verified in numerous instances, by 
noting the exact time when the pain commenced after the 
patient had passed a large and hard stool ; and on the next 
occasion for stooling, administering an aperient to produce 
a fluid dejection ; and then again observing the exact length 
of the interval occurring between the completion of the act of 
defecation and the accession of the pain, and I have gene- 
rally found but little variation in the length of the interval, 
the only difference, if any, it being in most cases longer 
after a fluid than after a large and solid stool; so much so 
that the patients themselves noticed the difference and began 
to imagine that they would escape the pain altogether. I 
have observed the same to occur in cases of anal fissure 
accompanied by diarrhoea. The pain after a soft or a fluid 
stool, as a general rule, is not as severe and of as long con- 
tinuance as after a hard one. Another fact should be taken 
into consideration in this connection, namely, that no incon- 
siderable number of patients suffer the greatest if not 
the only pain during the expulsive nisus, and whilst the 
anal orifice is being subjected to this very dilating and 
stretching process of which Dr. Van Buren speaks. 

I would also remark here, that, according to Dr. Van Bu- 
ren, the tonic contraction of the fibres of the sphincter ani 
muscle is the cause of the pain, for he holds that the pain is 
suspended until the full tonic contraction takes place. Now 
the fact is, that the full tonic contraction of this muscle takes 
place immediately after the evacuation, unless the distention 
has been so great as to produce paralysis of its muscular 
fibres ; for let any one then explore the anus, either with the 
finger or with the bougie, and he will find this muscle has 
already contracted naturally, and assumed its quiescent state. 
This contraction, in my opinion, does not therefore produce 
the pain, for this comes on some time after that has taken 
place. It requires something more than the mere tonic con- 



ANAL FISSURE. 87 

traction of the anal sphincters to bring on the pain. It 
would be more reasonable to suppose that it was in such 
cases the hyperaction, or the arbitrary or spasmodic con- 
traction of these muscles that caused the pain. 

The question before Mr. Quain was, why should there be 
in anal fissure, an interval of time between the completion 
of the act of defecation, the exciting cause, and the acces- 
sion of the pain, the effect ? He answers by saying, that 
he can give no satisfactory explanation of this circumstance. 
I also answer in the same language ; consequently I will not 
attempt an explication of it. The truth is, we are ignorant 
of the cause of this interval, neither can we account for its 
length, and we better admit, in the present state of our 
knowledge, that it is organic, and consequently that it de- 
pends upon some spontaneous change in the anus or anal 
canal itself, of which we know nothing. 

Mr. Malyn offers a very ingenious explanation of why, 
in anal spasm, the pain does not occur at the time of the 
excretion of the fseces ; and why it does occur some time 
afterwards. The question before him was, why should the 
pain take place after, instead of at the time of stooling ? The 
following is his explanation of this matter : " The inflamma- 
tory congestion of a part (the anus) possessing such strong 
and numerous sympathies, explains at once the fearful 
symptoms which attend it. The language of the patient 
appears to be exaggerated, and when he compares the sen- 
sation to that produced by the lodgment of a red-hot iron 
in the gut, or to the tearing it out with fish-hooks, it may 
seem strange that such should be the case, more after than 
at the time of the expulsion of the fseces. But we must 
remember that it is only to the most urgent calls of nature 
that he attends, and that the solid feces in their descent, a 
descent accomplished by violent abdominal contraction, 
stun or blunt the energy of the nerves, and so effect their 
exit with comparatively little pain. When, however, they 



88 ANAL FISSURE. 

are expelled, reaction takes place, the nerves re-acquire their 
sensibility, which is for a time exalted proportionally to its 
previous depression, and, until this state subsides, the parox- 
ysm endures." — (Op. cit.p. 339.) 

This explanation of Mr. Malyn is no less specious than 
that of Dr. Van Buren. They both, however, require large 
and indurated faeces to sustain them ; the former to produce 
the stunning or the blunting of the nervous energy, in order 
to suspend the pain at the time of stooling, and for some 
time afterwards ; and the latter to produce the stretching of 
the anal orifice, so that some time must elapse before the 
full tonic contraction of the stretched muscular fibres can 
take place, and the pain begin. A fluid evacuation, how- 
ever, in such a case, followed some time afterwards by the 
usual pain, is fatal to both hypotheses. Such a stool is 
effected without any stunning or blunting of the nervous 
energy whatever, — hence, according to Mr. Malyn, the pain 
should take place during the defecating act ; yet it does not 
do so, but comes on as usual some time after, and in the 
same manner as if the nervous energy had been stunned or 
blunted by the passage of a hard stool. 

The anus and anal canal being so much narrower 
than the rectum just above, the expulsion of faeces through 
this narrow passage is of course attended with more or less 
difficulty, in proportion to their size and solidity ; sometimes 
requiring all the power of the sphinctores ani, as well as that 
of the diaphragm and other abdominal muscles. When the 
faeces are fluid, the contraction of the muscular fibres of the 
inferior extremity of the rectum is alone sufficient for their 
expulsion, without the intervention of the anal sphincters. 
The gases are more easily expelled than faecal matter. Like 
fluid faeces, they can be disengaged by the action of the in- 
testine alone ; though the diaphragm and the other abdo- 
minal muscles generally co-operate with the intestinal circu- 
lar fibres in their disengagement. 



ANAL FISSURE. 89 

3. Symptoms and Signs of Anal Fissure in Infants. The 
symptoms of this disease in children differ somewhat from 
those manifested in the adult. In children or infants the 
pain occurs only whilst straining efforts are taking place ; the 
pain apparently ceasing in a few minutes after the passage of 
the faeces, only to reappear on the bowels being again moved. 
It is universally the case when infants are the subjects of this 
disease, that their sufferings commence and terminate with 
the act of defecation. Nothing appears to indicate the 
slightest pain after the excretion of the fsecal matter. Dur- 
ing the expulsive nisus the child manifests the acute pain it 
suffers by its actions, and by the sharp and piercing cries it 
utters. The pain appears to begin with the very first effort 
of defecation, and to be very severe during the passage of 
the faeces through the anus. When there is considerable 
constipation, which is sometimes the case in these instances, 
defecation is more painful, and often attended with violent 
spasm of the anus ; and there is also, at each and every evac- 
uation of the bowels, an escape of several drops of blood, 
consisting simply in an oozing, or a true stillicidium ani, but 
which immediately ceases on the cessation of the straining 
efforts. In adults extensive and very painful anal fissures 
often exist without the slightest haemorrhage. 

The fissure in infants is generally perceptible to the eye 
when the child is making straining efforts to evacuate the 
bowels, and the anus is everted ; but even in the absence of 
this ocular demonstration, the seat of the pain, the mode of 
its manifestation, and the slight haemorrhage which invariably 
accompanies each alvine evacuation, would leave but little 
doubt in the mind of the observer, as to the true nature of 
the case. 

Such are some of the rational symptoms and the signs of 
anal fissure, both in the adult and in the child, and they are 
quite sufficient to furnish a tolerable diagnosis. But in this, 
as in all other affections of the inferior extremity of the 



90 ANAL FISSURE. 

rectum, we must depend mainly upon the actual exploration 
of the parts, in order to determine its character positively. 
Such exploration requires considerable tact and dexterity to 
conduct it successfully. 



-o- 



Section III. — Physical Exploration, Diagnosis, and Prognosis. 

l. Ocular and Digital 'Examination. Preparatory to a 
thorough inspection of the rectum, and a few hours previous 
to making it, the bowel should be completely emptied by 
either a dose of castor oil, or a relaxing enema. Should 
there exist much pain and anal spasm immediately after the 
evacuation of the bowel, the following suppository should 
be administered a short time previous to making the ex- 
amination, unless it should be considered preferable to use 
an anaesthetic instead : — 

Recipe, Extracti Belladonnas, granum unam, 

Morphias Sulphatis, granum dimidiam, 
Butyri Cacao, scrupulum. 
Misce et fiat suppositorium. 

The rectum and the bladder being completely evacuated, 
the patient should be placed on his left side, on the edge of 
a bed, if high enough, or on the edge of a table, in front of 
a strong light; his head and shoulders depressed, his pelvis 
elevated, and his nates widely separated by an assistant. 

The first object of attention will be the external appear- 
ance of the anus itself, which in anal fissure is most always 
in a highly contracted state, and more or less infundibuli- 
form; indeed, in such a case the observer will be struck 
with the very considerable depth to which the anus is 
retracted, producing a quite unnatural appearance of it. 
Sometimes, however, in cases in which the fissure is 
located in the fossa between the two sphincters, the anus, 
instead of being firmly contracted, its external margin will 



ANAL FISSURE. 



9i 



present a peculiar laxity, and a bulging or jutting of one or 
the other side like a swollen lip. Another object that will, 
if it exists, attract the attention of the observer in this dis- 
ease, is a pendulous projection or polypiform body (Fig. 4), 




Fig. 4. 



varying in length from two to eight lines, and of different 
forms, composed of the integument at the margin of the 
anus, and existing in most all cases of any considerable 
duration. This condyloma or anal excrescence is always 
located at the base, or inferior extremity of the fissure, and 
is an unerring guide to it. I look upon this excrescence as 
being almost the pathognomonic sign of anal fissure ; and I 



9 2 



ANAL FISSURE. 



have seen but few cases indeed in which it was not present. 
By placing a finger on each side of the tumor, and pressing 
it out and down (Fig. 5), the fissure will be seen. 







Fig. 5. 

M. Velpeau mentions this excrescence. He says : " It is 
not unfrequent, in fissure, to find a hsemorrhoidal tuber- 
cle forming, as it were, its root, and receiving, so to speak, 
its tail." — {Loc. cit.) Mr. Syoie also notices it : " There is 
generally," says he, " a small, firm, red-colored pile, like a 
pea in size and form, at the base or outward extremity of 
the fissure, which tends not only to conceal the sore but to 
render its exposure more painful. To a practised eye, 
indeed, the peculiar form, consistence, and color of this 



ANAL FISSURE. 93 

little swelling render it a good guide to the seat of annoy- 
ance ; but it much more frequently misleads to the idea 
that there is no local complaint, or only an external 
hemorrhoid." — (Op. cit. p. 126.) Mr. Smith, in speaking 
of the same, says : " Not unfrequently a small tumor or 
hsemorrhoidal excrescence will be found at the verge of the 
anus ; on well exposing this, the fissure or ulcer will be seen, 
hid as it were behind it. In fact the existence of this small 
tumor is a pretty correct indication of the presence of the 
ulcer." — (Op >. cit. p. 128.) 

On proceeding to search for the fissure, which is often 
difficult to find, being hidden in the folds of the anus, the 
nates, as before observed, should be well divaricated by the 
assistant, while the surgeon should forcibly separate the sides 
of the anus with his thumbs, when the inferior extremity of 
the fissure will be brought into view, its edges will diverge, 
and its true character may be ascertained. 

When, however, the fissure is situated above the external 
sphincter of the anus, this proceeding will not suffice to 
bring it in sight, but a resort must then be had to the dila- 
tation of the anus by the use of the speculum ani, or by the 
introduction of the finger, in order to detect it. The exam- 
ination either with the finger or the speculum should not be 
made immediately after the evacuation of the rectum, if 
pain and anal spasm exist ; better wait for the effect of the 
suppository, or for a few hours until the pain and spasm 
shall have measurably ceased. Of course, if either ether or 
chloroform is employed, it is not essential to observe this de- 
lay. The existence, the exact situation and character of the 
fissure, may often be indicated by the finger alone introduced 
into the anus and anal canal, especially in a case of long 
standing. The lesion will be detected by the sensation com- 
municated to the finger, of roughness of its surface, or hard- 
ness of its edges ; or by a feeling of something like a hard 
wrinkled cord. Pressure should be made in every direction 



94 ANAL FISSURE. 

around the periphery of the canal. If the fissure is touched 
or pressed upon by the finger, its existence will also be con- 
firmed by the sensations of the patient, if not made insensi- 
ble by an anaesthetic, who will experience the most severe 
pain, as M, Dupuytren truly says when describing this dis- 
ease, " la pression fait ressentir beaucoup de douleursT — (Loc. cit?) 
The index finger of the right hand being warmed and 
well lubricated with either cacao butter, the simple cerate of 
the French pharmacopoeia, glycerine, the white of an egg, 
or olive oil, should be gently and gradually insinuated into 
the anal canal. Any attempt to penetrate roughly or rapid- 
ly will be very liable to excite resistance from the muscles, 
and the passage of the finger or other instrument would 
occasion more or less suffering and after-distress, and greatly 
interfere with the progress of the examination. I always 
use the butter of cacao for lubricating or besmearing the fin- 
ger, the speculum, the sound, the bougie, &c, in making 
an examination of the rectum, the vagina, the uterus, 
and the urethra. There is nothing better for this purpose, 
as it is soothing and relaxing, and not readily absorbed. 
I usually make the digital examination first, before using 
the speculum; the finger dilates the anus, and prepares the 
parts for the easy entrance of this instrument. The instru- 
ment I most use in anal fissure is the small bi-valve specu- 
lum ani, represented by Fig. 6. It, like the finger, should 




Fig. 6. 

be warmed and well lubricated before being introduced ; it 



ANAL FISSURE. 



95 



should then be gently and slowly passed up into the rectum, 
and opened and rotated until the whole mucous surface of 
the lower end of the bowel is clearly brought into sight. 
Should the view be obstructed in the least, by either mucus, 
blood, or fseces, a small mop made of fine sponge and at- 
tached to the end of a rod should be at hand to remove any 
of these matters. The instrument should be carefully with- 
drawn with the blades partially open. The only objection 
that can be urged against this valvular speculum, is that in 
instances, in which there is a superabundance of integument 
and mucous membrane at the anal extremity of the rectum, 
it too readily permits their protrusion between its blades, 
and thus more or less prevents an accurate inspection of the 
parts. The instrument is made of polished steel, or silver- 
plated. 

I have found the tri-valve trellis speculum ani, represent- 
ed by Fig. 7, a very valuable instrument for the purpose of 




discovering a certain kind of fissures or ulcers of the rectum. 
I devised it a number of years ago, as an instrument to be 
used in detecting the bleeding vessel in case of traumatic 
hemorrhage of the rectum. It is small when closed and 
easy of introduction, and when introduced admits of exten- 
sive expansion by simply revolving the handle. As an anal 
spec alum, especially in cases of fissure of the anus, I have 



96 anal fissure. 

also found the simple and highly polished steel instrument, 
in the form of a large blunt gorget, as delineated by- 
Fig. 8, very efficient and valuable. It is passed up into 




Fig. 8. 

the rectum upon the finger, with its concavity looking to- 
wards the seat of the disease, and when in to the depth of 
two and a half or three inches, the mucous surface of the 
canal at that height can be plainly seen reflected on its pol- 
ished concave surface ; at the same time the lower portion 
of the canal can be most accurately examined by the eye, 
by causing the patient to evert the anus as much as possible. 
By passing this instrument gently and slowly around the 
canal, the whole internal surface of it may thus be accurately 
inspected. It requires a strong and bright light. The idea 
of using an instrument of such a form was first suggested 
by Mr. Colles, who objected to the various kinds of anal 
speculse in common use, and employed for this purpose the 
large blunt gorget, and found it superior to any other. He 
subsequently made an improvement on it. In order to 
introduce it with greater facility he accurately fitted it to 
one side of a conical piece of polished box-wood, represent- 
ing in its transverse section a full ellipse, so that when both 
were joined they presented a perfectly smooth outline. 
After the instrument thus united was introduced to the pro- 
per depth the wooden plug was withdrawn. — {hoc. cit?) 

The instrument I designed is easy of introduction upon 
the finger, without the use of the plug. 



ANAL FISSURE. 



97 



On a dark day, or whenever a strong light is required in 
making rectal examinations, I always use the portable 
apparatus depicted in Fig. 9. It consists of a gas or oil 
lamp, with a reflector and a lens attached. 




G.TLEMANN & CO, 



Fig. 9. 



My son, Dr. W. H. Bodenhamer of Chicago, in examining 
the rectum in case of anal fissure, is in the habit of employ- 
ing the cylindrical speculum used for examining the condi- 
tion of the membrana tympani, with a prism attached to it. 
He considers this instrument preferable to any others for 
this particular purpose. 

2. Examination with the Probe, The method which I 
generally adopt in making the examination for anal fissure, 
obviates the necessity of distending the anus, — hence the 
extreme suffering consequent upon such dilatation is entirely 
avoided. No anaesthetic generally need be employed. I 
make the examination with a silver probe seven inches 

7 



98 



ANAL FISSURE. 



long and slightly curved at its distal end (Fig. 10). The 
probe should be dipped in glycerine or olive oil, 
jf and gently introduced some distance up the anal 
II canal ; then it should be brought down gradually, 

with its curved point pressing upon the side or wall 
of the canal, and as soon as it comes in contact 
with the fissure the patient will at once manifest it 
by the sensation of pain he will experience. This 
exploration with the probe may be continued 
around the whole circuit of the canal until the fis- 
sure, if any, is detected. 

3. 'The Diagnosis. Apart from the confusion that 
surrounds the subject, there is no disease of the rec- 
tum or anus in which the diagnosis is more easily 
established than in* anal fissure. The surgeon can 
always, by a physical examination, determine at once 
its presence or its absence in all doubtful cases. 
Indeed the manifestation of the disease is such that 
even the symptoms alone are, in most instances, 
IG * ia sufficient to establish the diagnosis beyond all doubt. 
The peculiar character of the pain ; the time of its access, 
either during or some time after an evacuation of the bowels ; 
its continued increase until it becomes agonizing ; and its 
gradual or its sudden decline and entire subsidence until the 
next evacuation, are circumstances which unmistakably char- 
acterise it. In describing this pain, the patients too generally 
use the most hyperbolic terms. In short, the question is not, 
Is the breach of surface of a peculiar form ? or is it attended 
by spasmodic contraction of one or both sphincters of the 
anus "? but it is — If the breach of surface of an exquisitely sensitive, 
or highly irritable and painful character ? This is the chief 
diagnostic ; and this is always easily decided by the sensations 
produced by touching the ulcer with the finger or the probe, 
or by the passage of the faeces over it in the act of defecation. 
I consider, too, that the peculiar time of the accession of the 



ANAL FISSURE. Q9 

pain is very important in the diagnosis of this disease ; 
though some may think it speculative, and of no real value. 
Nothing, however, should be neglected that would in the 
least tend to dispel the confusion in which this ingular 
affection has been involved. As far as it relates to spasmod- 
ic contraction of the sphincter or sphincters of the anus as a 
symptom of anal fissure, I would observe as before, that 
when it is caused by fissure, the pain is infinitely more acute, 
more intense, than when caused by any other disease of the 
mucous membrane of the inferior extremity of the rectum, 
— such as inflammation, irritation, tumefaction, haemorrhoids, 
etc. ; and also much more severe than when produced by 
disease in the genito-urinary organs. This purely spasmod- 
ic contraction of the anal sphincters, too, must not be con- 
founded with permanent or organic contraction of the anus, 
as is frequently done. The first consists of a spasmodic and 
accidental contraction only of the sphincter or sphincters of 
the anus; whilst the second consists of a permanent narrow- 
ing, thickening, and hardening of the orifice and canal of 
the anus. The second, however, is often the result of the 
first. 

Neuralgia of the Anus. Anal fissure is often'mistaken and 
treated for neuralgia of the anus, or inferior extremity of 
the rectum ; and, of course, with entire failure of affording 
any permanent relief A number of such instances have 
come under my own observation, and will be found report- 
ed in this work under the head, " Illustrative Cases." Dr. 
Bushe committed this error. He reports three cases, which 
he describes as neuralgia of the inferior extremity of the 
rectum ; but not one of them, in my opinion, was a true, 
genuine case of neuralgia; for the evidences of structural 
disease of the mucous membrane, at the exquisitely sensitive 
points described, are too clear, from which to draw any 
other conclusion. The complete success attending the 
operation of Dr. Bushe in one of the cases, tends to prove 



lOO ANAL FISSURE. 

that it was not neuralgic ; and in the third case the bloody 
and mucous discharge proved that in it there was some 
structural disease of the canal. — {Op. cit., p. 112.) 

Anal fissure is very readily distinguished from neuralgia, 
by the absence in the latter of any breach of surface, or of 
any other disease of the mucous membrane of the rectum ; 
by the entire w T ant of connection between the pain and the 
alvine evacuations ; and the constant suffering. In neuralgia, 
the pain caused by pressure with the finger in ano is not 
confined to one particular spot, as it is in fissure; but all the 
parts around the anus are tender alike. In anal neuralgia, 
too, instead of its being qften attended by spasmodic con- 
traction of the anal sphincters, the muscles will be found in 
a too relaxed condition. The pain of neuralgia is severe, 
but quite independent of contact. 

It is true that the morbid sensibility of the rectum and 
anus caused by a fissure, and that caused by neuralgia, are 
often so intimately blended, that it is sometimes no easy 
matter to distinguish between them; nothing but the detec- 
tion itself, in some cases, of the fissure, which can now 
always be discovered by a proper examination, will clear the 
diagnosis. 

Hemorrhoids. Anal fissure is often mistaken and treated 
for internal haemorrhoids. It is surprising how often this 
error is committed by practitioners, otherwise intelligent. 
The contrast between the two diseases is so great and so 
obvious, that it appears strange that such a blunder should 
ever be made; it is doubtless in consequence of the neglect 
of a proper examination. I will in the proper place report 
a number of examples of this error in diagnosis. Anal fis- 
sure and haemorrhoids are often associated, and when they 
are so, they are frequently treated simply as piles; — several 
examples of which will also be given hereafter. 

Uterine Affections. The symptoms of anal fissure in women, 
who are more liable to the disease than men, are generally 



ANAL FISSURE. 



101 



more severe and more complex, and very often simulate so 
closely uterine disease, that they are consequently well cal- 
culated to mislead the surgeon, and cause him to overlook 
the real seat and the true nature of the disease. A careful 
inspection, however, of all the parts concerned, will at 
once remove all errors in diagnosis, and dispel all doubts. 

Occult Fistula and Sacculi of the Anus. Anal fissure is liable 
to be confounded with blind internal fistulse, or with sacculi 
of the anus, as some of the symptoms of these two diseases 
somewhat simulate those of the former; that is, there is 
sometimes a more or less dull, heavy, aching pain after stool- 
ing, which, however, is by no means so severe and unbear- 
able, neither does it observe that regularity in coming on 
and in continuing to increase as the pain does in anal fis- 
sure, nor is it present at every evacuation, but several days 
may supervene and several evacuations may take 
place without its appearance, yet it may come on 
at the very next stool. These two diseases are 
never attended by anal spasm ; but there is always 
a more or less discharge of pus, which but seldom 
occurs in fissure. Blind internal fistulse and pre- 
ternatural pouches of the rectum are easily detected 
by a physical examination of the canal. It should 
be explored by means of a hooked probe (Fig. 1 1), 
as recommended by Heister (Institutions Chirurgica. 
Part //., Sect. V., Chap. CLXFlll. Amstelcedami, 
1739) and Dionis (Cours d* Operations de Chirurgie 
demonstrees au Jar din du Rio. Tome /., p. 405. 
Huitteme Edit. Par de la Faye. Paris, 1782). About 
half an inch of the distal end of the common silver 
probe should be bent back upon itself, so as to form 
a kind of hook, somewhat like that already recom- 
mended for examining anal fissure. The probe 
thus bent should be passed up the canal five or six F*g. n. 
inches, and then brought slowly back with the point bearing 



n 



102 ANAL FISSURE. 

successively on the different parts of the circumference of 
the rectum. Should an occult fistula or a sac exist, the 
reverted point of the probe will pass into its orifice and 
cavity, and render its existence and character at once 
sufficiently obvious. 

Syphilitic Sores about the Anus. Venereal ulcers in this locali 
ty, in the form of fissures, clefts, rhagades, etc., contrast re- 
markably with the real irritable and genuine anal fissure 
They are chiefly confined to the integument, or muco-cu- 
taneous coat about the anus, and seldom extend to any dis- 
tance within the anus. The edges are somewhat elevated 
and thickened, and the surface secretes an abundance of 
adhesive pus which forms crusts or scabs. These sores, as 
a general rule, are attended with but little pain at or after 
defecation, and by no spasmodic contraction of the anal 
sphincters ; and thus again contrasting greatly with genuine 
fissure of the anus. The characteristic appearance of the 
ulcer, its painless nature, the absence of anal spasm, and the 
class of persons affected, remove all doubt as. to the nature 
of the complaint. 

4. Complications of Anal Fissure. Fissure of the anus will 
often be found complicated with haemorrhoids, with condy- 
lomata about the verge of the anus, or with anal fistula ; or 
all these combined in the same case, several examples of 
which will be reported elsewhere in this work. It often co- 
exists with disease in the genito-urinary organs. Anal fissure 
is very liable, from the continued irrita:ion it produces in the 
parts, to result in fistula in ano. A number of such exam- 
ples will be found reported in this work. It also gives rise 
sometimes to spermatorrhoea, several cases of which I have 
met with in my practice ; also, to permanent organic con- 
traction of the anus, etc. 

5. The Prognosis. As a general rule, anal fissure is by no 
means an immediately dangerous disease ; yet it is one which 
is often accompanied by so much severe suffering, that it is 



ANAL FISSURE. 



10 3 



of the highest importance to afford as speedy relief as pos- 
sible. If the disease should be left to the resources of na- 
ture, it might continue for an indefinite period before the 
patient would finally succumb; as nothing authentic has 
been ascertained of its ever having been cured spontaneously, 
or without the aid of art. The general health of the patient 
is at first but little affected ; but when the disease has pro- 
gressed for some considerable length of time, his constitu- 
tion begins to fail, and he grows pale, sallow, and listless, 
and from continued suffering he becomes exhausted, falls 
into a state of gradual decay, and thus succumbs ; or he ulti- 
mately becomes attacked by some incurable organic disease, 
which carries him off. 



CHAPTER FIFTH. 



THE TREATMENT 



CHAPTER V. 

THE TREATMENT. 
Section l. — Precautionary and Palliative Measures. 

It is a source of regret that anal fissure, which is gener- 
ally the production of a slow morbid alteration of the parts, 
should receive so little attention from patients, except in its 
considerably advanced stage. The surgeon is scarcely ever 
consulted until the disease is fully developed. 

Constipation, if not the immediate cause of this affection, 
is nevertheless almost always an accompaniment of it, and is 
a constant source of its continuance. It is therefore highly 
important to the success of any treatment, that this condition 
of the bowels should be corrected, by securing their daily 
evacuation, and thereby preventing faecal accumulation. It 
should also be a primary object in these cases to prevent the 
formation of acrimonious matter in the bowels, and to take 
especial care to preserve an easy and regular transmission 
of their contents, which, for this purpose, should as much 
as possible be kept in a semi-fluid state, as figured or hard 
stools generally aggravate the symptoms. This must be 
effected by enjoining the most bland and unirritating diet, 
and by the use of emollient enemata or mild aperients. 
Purgative medicines, however, should be avoided as much as 
possible, as the mildest of them more or less stimulate and 
irritate the inferior extremity of the rectum. To accom 
plish the certain evacuation of the bowels every day, and 
the easy transmission of their contents, I generally recom- 
mend an enema of rich flax-seed tea, say from half a pint to 
a pint, to be administered every morning immediately after 



108 ANAL FISSURE. 

breakfast ; or I use the following, which is more effi- 
cient : — 

Recipe, Olei Ricini vel Olivae, unciam, 

Infusionis Seminum Lini tepidas, uncias octo. 
Misce et fiat enema. 

The enema should be repeated in half an hour, if the 
first should fail to produce the desired efFect. In the 
administration of enemata in these cases, in order to 
avoid as much as possible pain or injury to the high- 
ly sensitive parts affected, I use the gum-elastic jets, 
applied to the nozle of the enema syringe (Fig. 12). 
They are easily adjusted over the bone, wood, or metal 
enema pipe ; and being soft and elastic, are not so lia- 
ble to cause pain or do harm. 

If the persevering efforts in the use of enemata 
should fail to regulate the bowels, some mild laxative 
should occasionally be given to aid the injections. 
Great care, however, must be taken in the choice of 
such laxative ; the object being not to purge, but to 
render the fseces soft, so that as little stretching of the 
fissure as possible should take place. I often use the 
following aperient in such cases, with most excellent 
effect : — 

Fig. 12. Recipe, Sulphuris loti, 

Magnesia calcinatae, 
Saccholactin, ana, unciam. 
Misce et fiat pulvis. 

A teaspoonful of this powder should be taken in a little 
simple syrup an hour or two before breakfast. If it should 
fail to produce the desired effect, the same quantity should 
be taken night and morning. One stool only is required in 
twenty-four hours ; more than one aggravates the case. 

During the treatment of this disease, in order to lessen 
pain, it may be necessary to use fomentations to the anal 
region as hot as can be borne, applied in the form of either 



ANAL FISSURE. 



IO9 



flannel cloths or sponges saturated with plain or medicated 
hot water; or a large flax-seed poultice applied as hot as can 
be borne, and often renewed. When there is much inflamma- 
tion, congestion, and tumefaction, as in instances of long 
standing, the application of leeches, together with the fo- 
mentations, I have found highly beneficial in relieving the 
pain and spasm in those cases. Cold applications, however, 
are sometimes more grateful to patients suffering from anal 
fissure than hot ones, and may be tried when the others fail. 
Local anaesthesia is in some cases highly valuable, and may 
be employed, using for this purpose either sulphuric ether or 
rhigolene. 

One would suppose, from the locality and character of the 
large blood-vessels of the inferior extremity of the rectum, 
that the recumbent or horizontal position of the body, after 
evacuating the bowels, would relieve the pain, which in some 
instances it does to some extent, whilst in others it seems 
only to aggravate it. The horizontal posture, however, as 
a general rule, does afford more relief than any other position. 

I have recommended to a number of my patients the 
proceedings of M. Gossement as a palliative measure in anal 
fissure; who, after several trials, and becoming expert in its 
execution, have experienced the most happy results. M. 
Gossement's method, as given by M. Malgaigne, is as fol- 
lows : — "When the patient feels the desire to go to stool, 
he should moderately pinch, with two fingers, a portion of 
skin equivalent to almost one-sixth of the circumference of 
the anus, and comprising the fissure ; at the same time 
pushing from within outwards, so as to enlarge the anal 
orifice, and give a new fixed point, not bearing on the As- 
sure, to the sphincters; thus hindering the former from being 
dragged and strained by the passage of the excrements. In 
this way the pain is almost always avoided." — {Operative Sur- 
gery. English Version, by F. Brittan, M.D., p. 429. Philadel- 
phia, 1851.) 



] lO ANAL FISSURE. 



Section II. — The Treatment pursued by the Author. 

l. The treatment here laid down has been practised by 
the author for twenty-five years with invariable success. It 
will be observed that it consists of topical medication com- 
bined with dilatation, and sometimes incision or scarification. 

The chief indication in the treatment of anal fissure is to 
modify the surface of the ulcer, and transform it into a 
simple or a common sore, which then under ordinary 
circumstances will heal like any other solution of con 
tinuity. 

The treatment varies according to the stage of the disease 
and the locality of the ulcer. If the fissure is recent, very 
superficial, and not in the grasp of the external sphincter 
muscle, strict attention to the state of the bowels, and ablu 
tions with soap and water night and morning, and after 
each act of defecation, will usually effect a cure in a short 
time. The soap which I have used for years in such cases 
is BrecknelPs " Old Tellow English Soap ; " but of Tate I have 
used as a substitute the " Juniper Tar Soap " of Messrs. Cas- 
well, Mack & Co., of New York City, and found it very 
beneficial. Should this course, however, not afford relief in 
a short time, the following lotion, or the following oint- 
ment, may be used in addition to the ablutions, etc. : — 

Recipe, Sodae Chloridi, drachmas duas, 

Aquae destillatse, uncias duas. 
Fiat lotio. 

Pledgets of lint should be saturated with this lotion and 
kept applied to the anus by the T-bandage, and frequently 
renewed. Or the following ointment may be spread on lint 
and kept applied in the same manner : — 

Recipe, Unguenti Plumbi Acetatis, 

Oxydi Zinci, ana, unciam, 

Acidi Hydrocyanici, guttas viginti. 
Misce. et fiat unguentum. 



ANAL FISSURE. 1 1 1 

• 

When the fissure has existed for some time, and its edges 
are hard and elevated, they should be destroyed down to 
the bottom of the ulcer or sensitive parts, by the applica- 
tion of either the nitrate of silver, the acid nitrate of mercu- 
ry, or the nitric acid. Since 1842 I have used the nitrate 
of silver as a topical application in this disease with the most 
uniform and the most signal success. As an application in 
anal fissure, it is capable of producing several different effects. 
It lessens or calms the nervous irritation which so power- 
fully tends to induce spasmodic contraction of the sphinc- 
ters ; it coats and shields the raw and exposed mucous sur- 
face ; it removes the diseased and morbid action of the parts ; 
and it destroys the hard or callous edges. 

The form in which I usually employ this salt is in solu- 
tion, according to the following formula : — 

Recipe, Argenti Nitratis, drachmam, 

Aquas desdllatae, unciam. 
Fiat solutio. 

The solution should be applied to the fissure with a silver 
probe or a camel-hair pencil once in twenty-four or forty- 
eight hours, according to circumstances. The application 
is made by separating the margins of the anal orifice with 
the thumb and index-finger of the left hand, and introducing 
into the anus the probe or pencil charged with the solution. 
Should the fissure be more than the third of an inch above 
the margin of the anus, it would be necessary to use the 
speculum, especially if the camel-hair pencil is employed; 
and should there be much pain and anal spasm, it will be 
necessary to induce anaesthesia. The probe should be dipped 
in the solution and applied to the fissure only, if possible ; 
a few drops are all that is required. The first application 
generally causes very acute pain for twenty or thirty min- 
utes; this, however, maybe very much relieved by the appli- 
cation immediately after of glycerine, olive or almond oil, 
which will not in the least interfere with the good effects of 



112 ANAL FISSURE. 

the solution. After the immediate effect of the solution has 
subsided, it acts like a charm in calming the morbid irrita- 
bility of the fissure ; and by the third or fourth application, 
in all ordinary cases, the edges of the ulcer will exhibit that 
pearly color characteristic of approaching cicatrization. 

I have also employed the liquor potassa with singular good 
effect in some cases of anal fissure, applied in the same 
manner. It, like the former, allays the irritability of the fis- 
sure in an astonishing manner ; but I have noticed that 
cicatrization does not so readily and so rapidly follow its 
use as it does that of the nitrate of silver. The following 
mixture, as a topical application in anal fissure, has been 
highly extolled by M. Chapelle, of Angouleme : — 

Recipe, Spiritus Vini rectificati, drachmam, 

Chloroformyl, guttas quindecim. 
Fiat mistura. 

I have used this mixture in several cases recently with a 
very happy effect. The disease in these cases, however, 
was not of a very aggravated form. It must be applied to 
the fissure with either the probe or camel-hair pencil. 

In very aggravated cases, especially those of long stand- 
ing, I use the nitrate of silver in its potential or solid form. 
I usually cut a stick of the caustic to a point or angle, and 
passing it back and forth along the fissure rapidly for a 
minute, and then applying the glycerine or olive oil; or, 
what is still better, I coat the end of a silver probe by dip- 
ping it into the fused nitrate of silver, and applying it to the 
fissure. It generally requires but two or three applications 
of the solid nitrate of silver to effect a cure. I have also, in 
aggravated cases, used the liquid acid nitrate of mercury, and 
the nitric acid, with the most happy results. Great care, 
however, must be taken in the use of these powerful agents. 
They must be applied to the fissure by means of a small 
glass probe. The probe is dipped in the liquid, and a drop 
or two adhering to it is quite sufficient. The cure is effected 



ANAL FISSURE. 



"3 



frequently by two or three applications, several days interve- 
ning between each. To aid in destroying the hard and elevated 
edges of the fissure, besides the other treatment, I sometimes 
scarify them every few days with a small sharp-pointed lancet. 
In those ulcers located in the fossa between the two 
sphincter muscles, in addition to one or the other of the ap- 
plications already named, I have used with most decided 
good effect the following ointment : — 

5 Hydrargyri Oxydi cinerei, drachmam dimidiam, 

Cerati Simplicis, unciam unam. 
Misce et fiat imguentum. 

The ointment should be applied immediately to the af- 
fected part by means of the suppository 
tube. The tube should be well lubri 
cated on the outside with the ointment; 
then it should be charged with from 
half to a teaspoonful of the same, and 
passed into the anal canal to the depth 
of an inch, an inch and a half, or a little 
beyond the ulcer, and the piston pushed 
down. Or the ointment may be intro- 
duced by means of the valuable breech- 
loading syringe for administering semi- 
solid substances, devised by Dr. J. C. 
Hutchison and improved by Mr. Stohl- 
mann. This instrument, represented by 
Fig. 13, is far preferable to the sup- 
pository tube for this purpose. It is 
made of hard rubber, and consists of a 
hollow cylinder and a staff. The staff 
is nothing more than a tube, the end of 
which passes through an opening into 
the chamber, and is attached to a piston 
having a perforation in its centre corre- 
sponding to that in the tube. From the shoulder on the 

8 




114 ANAL FISSURE. 

staff to the upper portion of the chamber is a spiral spring 
which draws up the piston to the top of the internal portion 
of the cylinder, and thus enables the syringe to be easily 
filled. The lower end of the cylinder has a screw-cap, which 
can be removed for the purpose of loading it with semi- 
solid substances, such as ointments and the like. The ad- 
vantages of the instrument over others of its sort are, that 
it can be worked easily with one hand, by bracing it in the 
hollow of the palm and pressing upon its shoulder with the 
two fore-fingers, and, when ointment is used, the lack of 
danger in soiling the wristband or coat-sleeve by any re- 
gurgitation. The principle upon which it works is obvious, 
the pressure of the piston upon the column of fluid or semi- 
solid forcing the substance through the tube. The shoulder 
is provided with a screw on its upper surface, to which can 
be attached any sized tube for the different canals of the 
body. It is of course only really useful in those cases which 
do not require a continuous injection, or more than one 
charge of the fluid at a time, and hence will answer a good 
purpose in hemorrhoidal affections where an anodyne oint- 
ment is indicated ; and in various affections of the urethra, 
throat, ear, uterus, &c. In most cases the patient can make 
the application without assistance. — (^The Medical Record. 
Vol. III pp. 95, 166. New Tork, 1868.) 

The ointment should be introduced shortly after the evac- 
uation of the bowels, and not more than once in twenty- 
four hours. As a good substitute in such cases, the follow- 
ing ointment may be used in the same manner : — 

Recipe, Calomelanos, grana viginti, 

Axungie, unciam. 
Fiat unguentum. 

The anal excrescence or condyloma which is most 
always present in this disease, and which is evidently 
caused by the irritation or inflammation of the fissure, gen- 
erally gets gradually less as the fissure heals, and the ir- 



ANAL FISSURE. 1 l^ 

ritation of the parts subsides, and ultimately disappears. 
Should it, however, not do so, it must be snipped off with the 
curved scissors ; or removed by the application of chromic 
acid, the chloride of zinc, or the potassa fusa. 

2. Distention of ike Spasmed Anal Sphincters. When the fis- 
sure is accompanied by spasmodic contraction of one or 
both sphincters of the anus, the healing of the ulcer is more 
or less protracted in consequence of such constriction, which, 
although a mere symptom, is nevertheless a source of con- 
siderable mischief, as it occasions much additional pain by 
compressing the fissure and preventing the healing of it as 
rapidly as it would otherwise do. ' This spasmed state of the 
sphincter ani muscles should therefore be overcome by treat- 
ment, in addition to, and separate and distinct from that of 
the fissure itself; not, however, by having recourse to section 
of the sphincter muscles according to M. Boyer, but by the 
milder, safer, and equally certain method of distending them. 

The object of employing distention of the sphincters by 
either the bougie, the fingers, or tents made of lint, is not 
only to produce relaxation of the constricted muscles, but 
also, by the firm pressure, to render them less irritable, and 
consequently less susceptible of the sympathetic impressions 
of the fissure, which are in reality the cause of the spasmodic 
contraction. Previous to using the bougie in such cases, 
I always make a few applications to the fissure of the 
nitrate of silver, which, by shielding the mucous membrane, 
and removing the nervous irritability of the parts, materially 
facilitates the introduction of that instrument, and thus ren- 
ders the dilating process easy and comparatively free from 
pain. In cases in which the sphincters are powerfully con- 
tracted, I administer the following suppository about one 
hour before introducing the bougie : — 

Recipe, Extracti Belladonnas, granum unam, 

Butyri Cacao, scrupulum. 
Misce et fiat suppositorium. 



Il6 ANAL FISSURE. 

This may be administered by means of the suppository 
tube, the breech-loading syringe, or it may be rendered fluid 
by warmth and injected into the rectum with a small syringe. 
It is invaluable in such cases, as it relaxes to a considerable 
extent the muscular constriction, and greatly assists in the 
distention of the anus and anal canal, while it lessens the pain 
arising from such distention. The effects of the belladonna, 
however, must be closely watched, as in some instances bad 
results follow its too free and indiscriminate use. Sir Ben- 
jamin Brodie, on this account, discarded it altogether. I 
have never witnessed but one case in which alarming symp- 
toms presented themselves from its use, and that was a case 
in which the belladonna ointment had been without judg? 
ment excessively used. If the dilatation is carefully and 
gradually made, I have always found that the introduction 
of the bougie, excepting the first time, is attended with but 
little pain. Every time it is inserted the pain is less. The 
bougie should not be used when the patient is suffering 
severely; better wait several hours after stooling, or just 
before the evacuation, when all the parts are in a quiescent 
state. Should anaesthesia be determined on, however, the 
bougie could be used at any time. 

For the purpose of dilating the anus and anal canal I use 
wax bougies of gradually increased sizes, commencing with 
a number three. The English rectal bougie, however, 
answers very well for this purpose. The bougie must be 
passed through the constricted portion of the canal, and im- 
mediately withdrawn ; but it should not be so large, neither 
should the force be so great, as to lacerate or rupture the 
mucous membrane or muscular fibres, this not being con- 
templated by the operation of distention or dilatation. The 
gradual dilatation of the sphincters, and lower end of the 
rectum, if judiciously performed, is speedily followed by 
great relief, and ultimately by complete recovery. 

When anal fissure is caused by aphthse or canker, which 



ANAL FISSURE. 117 

is sometimes the case, several marked instances of which 
having come under my own observation in nursing mothers, 
as well as in others, I apply to the fissure the nitrate of sil- 
ver, and at the same time inject from half to a teaspoonful 
of the following ointment, night and morning, into the anal 
canal by means of the suppository tube, or breech-loading 
syringe : — 

Recipe, Bismuthi Trisnitratis, 

Glycerine, ana, drachmas duas, 
Cerati Simplicis, unciam. 

Misce et fiat unguentum. 

Whilst these applications are being made, I recommend 
the patient to take a teaspoonful of the following powder 
three times daily. It should be taken at meal-times, well 
mixed in as much water as will make it thin enough to 
drink : — 

Recipe, Pulveris Bismuthi Trisnitratis, 

Acacias, ana, unciam, 

Sodas Bicarbonatis, semi-unciam, 

Zingiberis, 

Sacchari purificati, ana, drachmas duas. 



Misce et fiat pulvis secundum artem. 

I have also used the ftotassa chloras in such cases with a 
most happy effect. To an adult, from twenty to thirty grains 
in solution may be given three times daily. To an infant 
one year old, from three to six grains in solution may be 
given three times daily. I have found this an invaluable 
remedy in follicular and in ulcerative stomatitis. 

If this treatment is persevered in for eight or ten days, 
with strict attention to diet, it will without fail result in a 
cure of both the aphthae and the anal fissure. 

3. tfhe Author's treatment of Anal Fissure in Infants, In the 
treatment of the fissure of infants, I first administer an ene- 
ma of flax-seed tea and olive oil, to empty the rectum, and 
whilst the parts are protruded in the act of defecation, I ap- 



n8 



ANAL FISSURE. 



ply the nitrate of silver in solution to the fissure, which is 
plainly brought into view by the straining efforts of the 
child. The application can be made in an instant, and be- 
fore the parts return. The butter of cacao, glycerine, or 
olive oil, should at the same time be applied to the fissure, 
as well as to all the parts. One hour after this is done, I 
administer the following astringent and tonic enema, which, 
if possible, is to be retained : — 

Recipe, Extracti Rhataniae, grana quinque, 

Aquas Rosarum, unciam. 
Misce et fiat enema. 

These measures should be repeated once every twenty- 
four hours until the cure is completed. If constipation of 
the bowels obtains, and the relaxing enema does not relieve 
it, mild aperients should be used in addition. 

In the fissure of infants, caused by and complicated with 
aphthae, I apply the solution of the nitrate of silver and the 
ointment of bismuth to the fissure, whilst I recommend the 
following infusion and powder to be given to the child. A 
teaspoonful of the infusion should be given every three or 
four hours to a child six or eight months old ; and three or 
four grains of the powder should be applied every few hours 
to the child's tongue, by which it will be carried over its 
mouth : — 

Recipe, Pulveris Ipecacuanhas, grana sex, 
Tincturae Opii, guttas quatuor, 
Olei essentialis Menthae piperita^, guttam unam, 
Sacchari purificati, drachmam, 
Aquae bullientis, uncias tres. 
Fiat infusio. 

Recipe, Pulveris Boratis Soda?, 

Sacchari purificati, ana, scrupulum. 

Fiat pulvis. 

This treatment persistently followed will soon relieve 
both the thrush as well as the fissure. 



ANAL FISSURE. H9 

Anal fissure in children is often caused by erythema of 
the anus, and when this is the case, all the affected parts 
should be treated. Attention to cleanliness is of the ut- 
most importance to bring about a cure of both the erythe- 
ma and the fissure. Bathing the parts frequently with soap 
and water, and with the infusion of marsh-mallow or flax- 
seed, or gum-arabic water, will tend greatly to expedite the 
cure. It is important to change the linen frequently. In 
these cases I have found great benefit by the frequent appli- 
cation of the pulvis lycopodii to the whole diseased surface. 
It protects it in the most perfect manner possible, for it is 
not pervious to liquids, and water runs off its surface. It is 
far preferable to starch, which when moistened forms a crust 
which is difficult to remove. The bismuth ointment, sim- 
ple cerate, cacao butter, or fresh lard, are good applications. 
One or the other should be spread on lint and kept applied 
to the anal region by the T-bandage or by the diaper. 

By this simple treatment I have never failed to effect a 
cure in a short time. 



o- 



Section III. — The Different Methods of Treatment. 

The various methods which have been recommended, 
from the earliest times to the present, for the cure of anal 
fissure, may be comprised under the following heads : — 

First — Topical applications of numerous and various 
kinds, including enemata, both simple and medicated, and 
suppositories. 

Second. — Cauterization, with either the potential or the 
actual cautery. 

tfhird. — Dilatation of the anal sphincters. 

Fourth. — Incision of the mucous membrane of the anal 
canal, together with the sub-mucous cellular tissue ; or scari- 
fication of the fissure. 



120 ANAL FISSURE. 

Fifth. — Excision of the fissure. 

Sixth. — Complete division of the sphincters of the anus. 

l. topical Applications. Some authorities say that anal 
fissure can never be cured by topical applications, that at 
best they can only palliate ; others again even go so far as 
to say, that they only aggravate the disease. This, how- 
ever, is not true, for hundreds of instances can be adduced 
in which some of the most aggravated cases have been 
cured by such measures. Even M. Boyer himself, who de- 
nounced all such treatment as worse than useless, gives an 
instance in which he succeeded in curing a case of anal fis- 
sure, accompanied by spasmodic contraction of the anal 
sphincter, by injecting into the rectum two or three table- 
spoonfuls, three or four times daily, of the following ad- 
mixture : — 

Up Expressed Juice of House Leek (Sempervivum Tectorum), 

of Garden Nightshade (Solanum Nigrum), 

Olei Amygdalae, ana, ^ iv. 
Axungie, I iij. 

Fiat mistura secundum artem. 

This mixture, made moderately warm, was injected with 
a small syringe. — (Op. cit. p. 612.) 

To those who contend that topical applications are at best 
mere palliatives, and do not cure the disease, I reply that 
division of the sphincters is only palliative, and does not 
eradicate or break up the morbid condition of the parts. 

M. Dupuytren reports a number of severe cases of anal 
fissure which were cured by his celebrated ointment, intro- 
duced into the anus on pledgets or tents of lint. The fol- 
lowing is a report of one of his cases : — " A healthy young 
woman had been affected for some weeks with very violent 
pains in the anus whenever she went to stool, especially 
when the faeces were hard. At first these pains continued 
only for a few minutes, but afterwards they persisted longer, 
and finally continued during some hours. When she 



ANAL FISSURE. 121 

entered the Hotel Dieuher anus was examined with care 
by M. Dupuytren, who discovered there a very superficial 
fissure. The constriction of the anus was very consider- 
able ; the finger could not be introduced into it without 
great difficulty and causing great pain. Unwilling to sub- 
ject the patient to the pain and inconvenience of an incision 
or cauterization, M. Dupuytren prescribed the introduction 
into the anus of a roll of lint, besmeared with his belladonna 
ointment, and renewed every time the patient went to stool. 
This ointment calmed the pains, and in a few days they 
entirely ceased, and the patient was entirely relieved of 
her disease. — {Revue Medicate. Home I. p. 869. Pans, 1829.) 
M. Beclard, who reports numerous cases of anal fissure, 
declares most positively that he never failed to cure them 
by the application of the nitrate of silver in its solid or po- 
tential form, and at the same time employing dilatation of 
the anal sphincters by the use of the bougie. — (Archives 
Generates de Medecine. Home VII. pp. 310, 339, Paris, 

1825.) 

M. Delaport publishes a case of anal fissure of an aggra- 
vated character, in which he used an ointment of belladonna 
with the happiest effect, after many other remedies had 
been tried without avail. The ointment was made by mix- 
ing one drachm of the extract of belladonna with half an 
ounce of simple cerate. A roll of lint was smeared with 
this ointment and introduced into the rectum. The relief 
was prompt. He prefers this treatment to dividing the 
sphincters, and does not object to touching the fissure at 
the same time with the nitrate of silver, by which the. pain 
is suddenly relieved. He mentions instances in which the 
operation of dividing the sphincter muscles entirely failed. 
— {Observations sur Vheureux emploi de ta bettadone dans un cas de 
fissure et de constriction spasmodique de Vanus. In Journal 
General de Medecine. Home CX. p. 329. Paris, 1839.) 

M. Laborderie reports a similar case to that of M. Dela- 



122 ANAL FISSURE. 

port, in which he succeeded in effecting a complete cure by 
the use of the following ointment : — 

Recipe, Extracti Belladonna?, drachmam, 

Liquoris Plumbi Subacetatis diluti, semidrachmam, 
Cerati Simplicis, semiunciam. 

Fiat unguentum. 

(Revue Medic ale de Paris. Juillet 3 1830.) 

M. Pagen speaks in the highest terms of a mixture of 
opium cerate and the extract of monesia, as being remarkably- 
successful in the treatment of anal fissure. — {Gazette Medi- 
cale. 'Tome Fill. No. 4. p. 59. Pans, 1840.) 

M. Lamoureux states that he succeeded in curing anal 
fissure by employing belladonna. — (Societe de Medecine de la 
Seine-Infer. Tome IX. fi. 78.) 

M. Descunde says that anal fissure may be cured by ad- 
ministering the oil of hyoscyamus in large doses by the 
mouth, at the same time employing mercurial ointment as 
a topical application. — (Motfs Felfieau. Vol. III. fi. 1112. 
New York, 1847.) 

M. Mothe cured anal fissure by topical applications, 
principally in the form of lotions. — (Archives Generates de 
Medecine de Paris. Tome XFll.fi. 648. Also, Memoires sur 
les Fissures a VAnus, In Melanges de Medecine et de Chirurgie. 
Tome 11. fi. 31 . Paris et Lyons, 1827.) 

Chelius reports having cured cases of anal fissure with the 
ointment of zinc smeared on bougies and introduced into 
the anus. — {hoc. cit.} 

This disease, according to the testimony of some of the 
most eminent French authorities, has been most successfully 
treated by the use of rhatany. The distinguished M. Breton- 
neau of Tours in France appears to have been the first who 
employed and recommended this agent in the treatment of 
fissure of the anus. He was led to try the effect of the 
rhatany in this disease, trom having observed that constipa- 
tion was in most cases the cause of anal fissure, and the ob- 



ANAL FISSURE. 123 

stacle to its cure. That this constipation was in a great 
majority of cases attended with an unnatural dilatation of 
that portion of the rectum immediately beyond the internal 
sphincter ani, which thus formed a place of lodgment for 
the feculent matters, which sometimes accumulated there to 
such an extent as to be expelled with great difficulty. To 
correct this morbid condition of the pouch of the rectum, 
whether accompanied by fissure or not, and to restore it to 
its natural tone and action, was the object which M. Breton- 
neau had in view in employing the rhatany. In several 
cases then of this condition of the rectum, attended by anal 
fissure, he discovered that he effected a cure both of the 
constipation and the fissure, by administering the extract of 
rhatany in a fluid state as an enema, with the addition of a 
small quantity of the tincture of the same. 

After M. Bretonneau had thus introduced and made 
known this method of treating constipation and fissure of 
the anus, his celebrated pupil, the late and lamented M. 
Trousseau, followed it up with great success in the treat- 
ment of anal fissure. The method in which he employed 
it in this disease is as follows : — He administered to his 
patient every morning an enema of the decoction of marsh- 
mallows, or simply of water, with the addition of olive or 
almond oil, in order to clear out the rectum. In half an 
hour after the bowel had thus been emptied, he administer- 
ed the following enema : — 

Recipe, Extract! Rhatanias, drachmas duas, 

Spiritus Vini rectiiicati, drachmas quinque, 
Aquae purae, uncias quatuor. 

Fiat enema. 

This injection he required the patient to retain, if possi- 
ble ; and a similar one to be repeated in the evening. 
When the pain was once moderated he only administered 
one daily, and when the cure appeared to be completed, 
only one every alternate day for about two weeks longer. 



124 ANAL FISSURE. 

He says he derived considerable advantage in the treatment 
of fissure of the anus, by the employment of an ointment 
composed of one or two parts of the extract of rhatany to 
five parts of the butter of cacao. 

M. Duclos reports the two following cases of anal fissure 
in infants which were both successfully treated by M. 
Trousseau, the first in the Hospital Neckar, and the second 
in private practice : — 

Case First. This was the case of a little girl one year old, 
under treatment for a white swelling of the knee. This 
child had been constipated from her birth, but more especi- 
ally for the four previous months, the bowels being moved 
only every third or fourth day. Two months previous, the 
mother remarked that every time the bowels were opened 
the child screamed violently. The pain appeared to com- 
mence with the effort of defecation, to continue during the 
passage of the faecal matter, and to be prolonged for a few 
seconds afterwards. For the last month, more especially, 
defecation had been exceedingly painful, and at each stool 
the child had voided a few drops of blood, either before or 
after the fseces, but never mixed with them. Sometimes 
the child, after a violent effort, would void a few drops of 
pure blood, scream violently, and make an effort as if to 
prevent the escape of fseces, in which no stool took place. 
The general health was very good. On examination of the 
anus, the following was found to be the state of the parts : 
— The circumference of the anus was perfectly healthy, 
but on deeply separating the folds, at the anterior part, 
and between two folds of skin, a fissure, a millimetre in 
width, and about five millimetres in length, of a red color, 
was distinctly perceived. It was the more clearly seen as 
the child, screaming violently, protruded the anus. The 
constriction of the anus was so great, that the extremity of 
the little finger could scarcely be introduced. M. Trousseau 
prescribed an enema, composed of the extract of rhatany 



ANAL FISSURE. 12^ 

one scruple, and water three ounces. The child kept the 
injection four or five minutes, and passed it along with soft 
faeces. The injection was repeated daily for five days. 
Each time the passage of the fseces appeared less painful, 
and on the sixth day the injection was discontinued. The 
motions were then easy, free from blood or pus, and 
unaccompanied by pain. The child left the hospital ten 
days after, quite cured of the anal affection. 

Case Second. This was the case of a child eight months 
old, well developed, and in previous good health; had been 
suckled by the mother until the age of six and a half 
months. At that epoch it was weaned, and was subsequent- 
ly attacked with violent diarrhoea, which gave way under 
the use of emollients. The diarrhoea was followed by 
obstinate constipation. This state had existed for about 
eight days, when the child was seized, during defecation, by 
violent pain at the anus, and the fseces were found tinged 
with blood. From that time the child suffered great pain 
on defecation and for some minutes afterwards. The fseces 
were hard, and generally tinged with a few drops of blood. 
The child was constipated. General state satisfactory. On 
examining the anus, around its orifice was found a little 
erythema and eczema which had been occasioned by the 
diarrhoea, and were fast disappearing. Behind and to the 
left, on separating the folds of the anus, a fissure about two 
millimetres in length and one in depth, of a rosy color, was 
discovered. It was very distinctly seen on the child's pro- 
truding the anus in an effort of defecation. The anus was 
considerably constricted. The same treatment was adopted 
as in the first case. The fissure cicatrized completely in 
about ten days, all pain on the evacuation of the fseces dis- 
appearing. — (London Lancet. Fol.lV.p.\$~]. London, 1846. 
From the Journal de Chirurgie. Annie 1846.) 

The late and lamented Professor Velpeau rejected the 
idea of curing a true anal fissure with such a remedy as 



126 ANAL FISSURE. 

rhatany. In remarks which he made within a year of his 
death, on "The Affections of the Anal Region" he says: — 
" Formerly all ulcerations of the anus were confounded un- 
der this name (anal fissure), and many practitioners still con- 
found them. It was exactly in regard to this that M. Boyer 
made his essay, which has remained one of his remarkable 
works. He perfectly showed that it was necessary to dis- 
tinguish on one side the fissure, properly so called, — that is 
to say, a crack sufficiently cleanly cut, a little indurated, or- 
dinarily perpendicular to the sphincter; this is never cured 
without an operation, and all the ointments in the world can 
accomplish nothing." 

" But on the other side, superficial excoriations also exist 
near the anus, having no particular characteristic ; these are 
the ones M. Trousseau cures by rhatany ; and in making 
use of this word fissure he has brought back to us the con- 
fusion of the times before Boyer, and against which I wish 
to guard you." — (Lessons upon the Diagnosis and 'Treatment of 
Surgical Diseases, &c. Translated by JV. C. B.Fifield, M.D. p. 
90. Boston, 1866.) 

From the above it is evident that M. Velpeau did not 
consider that the cases which M. Trousseau treated as fissure 
of the anus were in reality that disease, but were mere ex- 
coriations of the anus, &c. In this, however, he has done 
M. Trousseau great injustice, as I will show. What, I ask, 
is a true anal fissure? I will let M. Velpeau himself answer 
the question. He says : — " Three essential symptoms charac- 
terize fissure at the anus; first, burning pains at the moment 
of passing the stools ; second, a superficial, narrow, long 
ulcer, or sort of crevice, at the entrance of the intestine ; and 
third, a violent and painful constriction of the sphincter." 
— (Motfs Velpeau. Vol. III. p. 1 ill. New Tork, 1847.) 

Now let the reader. refer to the two cases of M. Trousseau 
as presented above in full, which were treated successfully 
by the use of rhatany, and let him compare their descrip- 



ANAL FISSURE. \2~] 

tion carefully with the description of anal fissure given by 
M. Velpeau himself, and he will find them to correspond 
exactly. If those two cases were not cases of true anal fis- 
sure, then, I ask, what constitutes a true anal fissure ? I 
could, in addition to the two cases of children reported 
above, give a dozen cases of true anal fissure in adults suc- 
cessfully treated by M. Trousseau by the use of rhatany. 
These cases would be found to possess all the characteristics 
of genuine fissure according to M. Velpeau — namely, severe 
burning pains whilst stooling, or a short time afterwards ; a 
long, narrow ulcer about the verge of the anus, and painful 
anal spasm. 

These two pre-eminently great men of our profession, 
MM. Trousseau and Velpeau, have both lately, and within a 
short period of each other, rested from their earthly labors, and 
their works do follow them. These will remain as imperish- 
able monuments of their genius and industry, and entitle 
them to a high and distinguished rank among the benefac- 
tors of mankind. 

M. Marjolin treated a case of anal fissure successfully by 
the use of rhatany alone. Cabanellas (These de Paris. No. 
132. Annie 1826). 

2. Cauterization. The indication contemplated by the use 
of the cautery, either in its potential or in its actual form, in 
the treatment of anal fissure, is to effect a change in the surface 
of the fissure or ulcer, and thus to convert it into an ordinary 
sore. The potential cautery has been employed in the treat- 
ment of this disease from an early day down to the present 
time, doubtless with more or less success. The treatment 
of Guido de Cauliaco and Dionis consisted chiefly in the 
scarification and cauterization of the fissure. The following 
articles as caustics have been, and are now, sometimes used 
in the treatment of this disease — Caustic potash, potassa 
cum calce, nitrate of silver, sulphate of copper, acid 
nitrate of mercury, the mineral acids, chloride of zinc, &c. 



128 ANAL FISSURE. 

M. Jules Guerin, on the authority of M. Boyer, has the 
merit, if any, of first recommending and employing the 
actual cautery in the treatment of anal fissure in modern 
times. M. Boyer, however, very justly remarks that it can- 
not be employed without great inconvenience, except in 
those cases of fissure unattended by spasmodic contraction 
of the anal sphincters. — (Op. cit. p. 612.) 

3. Dilatation. The object of employing dilatation of the 
sphincters of the anus in instances of anal fissure, accompa- 
nied by spasmodic contraction of one or both of these mus- 
cles, has already been explained in another place. It may 
be well, however, again to refer to the subject here. I have 
elsewhere shown that the spasmodic contraction of these 
muscles not only adds greatly to the pain of the fissure by 
compressing it, but that it more or less retards the healing 
of it, — hence the great importance of the distention of these 
spasmed muscles, which destroys or suspends, for a longer 
or shorter time, their contractility, without inflicting any 
permanent injury upon them, and completely relieves the 
fissure from their grasp and compression, and enables it, by 
proper applications, to cicatrize so much more rapidly. 

The same object, it is true, is accomplished by the divi- 
sion of one or both of these muscles with the knife, but not 
without serious danger and great inconvenience. The same 
object is also partly attained by the anti-contractile property 
of belladonna. 

Dilatation of the anus and inferior extremity of the rec- 
tum, except in organic or permanent stricture of the anus 
and rectum, was, so far as my reading extends, first alluded 
to by Ambrose Pare. — (Loc. cit.) In 1815 Mr. Copeland 
highly recommended it, and successfully employed it in the 
treatment of several cases of what he called spasmodic con- 
traction of the sphincter ani muscle. — (Loc. cit?) A short 
time subsequently Mr. Gaitskell employed it with equal 
success in a similar case (loc. cit.'), and in 1 824 Mr. How- 



ANAL FISSURE. 12 

ship also employed it successfully in a case of the same 
kind. — (hoc. cit.) These gentlemen denominated their cases, 
simple painful spasm of the sphincter ani, but, as I have else- 
where shown, they were without doubt all clear cases of 
anal fissure. 

The principle of muscular distention and dilatation was, 
however, in 1838, most thoroughly investigated in a valua- 
ble paper on " Extension, Shampooing, and Percussion, in the treat- 
ment of Muscular Contractions" by the able and ingenious M. 
Recamier, the then distinguished physician of the Hotel 
Dieu of Paris. In this paper M. Recamier observes that 
the peculiar functions of all organs of the body may be dis- 
turbed, either directly or indirectly, — the deviations from 
health being in many cases dependent upon the state of an 
organ at a distance from the one which exhibits the morbid 
phenomena. The contractile functions of the muscles, in- 
voluntary as well as voluntary, not unfrequently exhibit 
the truth of this remark. M. Recamier closes this very 
interesting and instructing paper by declaring the following 
conclusions : — 

First. It is necessary to discriminate those spasms or 

,muscular contractions which are not dependent upon, or 

proceed from, an affection of the nervous system, but which 

constitute a direct lesion of the contractile functions of the 

voluntary or involuntary muscles themselves. 

Second. In idiopathic muscular contractions, in wry-neck, 
in dyspnoea, in spasmodic colic, in spasms of the sphincters, 
etc., the use of extension, compression, and shampooing, 
and the application of the cupping-glasses (dry cupping), 
seem to be by far the most efficacious means of treatment. 

Hhird. Hence it is scarcely ever necessary to have re- 
course to section of the contracted muscles in torticollis, or 
in contractions of the sphincter ani ;] except in cases in 
which there exists an actual degeneration or a morbid change 
of structure in the part itself. 

9 



I30 ANAL FISSURE. 

M. Recamier was consulted by a lady who had long suf- 
fered severely from a fissure of the anus, for which M. Boy- 
er had divided the sphincters of the anus. The operation, 
however, did not prevent a relapse of the disease, and the 
patient continued to suffer dreadful pain in the rectum, 
especially when stooling. Dilatations of the sphincters and 
of the lower end of the rectum, by means of bougies grad- 
ually increased in size, ultimately succeeded in effecting a 
perfect cure in this interesting case. 

This eminent physician reported several other cases of 
anal fissure, accompanied with painful constriction of the 
anus, and some of them complicated with haemorrhoids, in 
which the use of gradual distention of the anus and anal canal 
was speedily followed by great relief, and finally by com- 
plete recovery. He adds that the operation of dividing the 
sphincters may be dispensed with in the majority of cases. 
, — (Revue Medicate de Paris. Janvier, 1838.) 

In the distention or dilatation of the anal sphincters, M. 
Recamier did not contemplate any rupture, laceration, or 
tearing of the mucous lining, or any of the muscular fibres of 
the intestine. 

turunda, or Merits. Dilatation of the anal sphincters and 
rectum in this disease may be effected by the introduction 
into the canal of tents made of lint and gradually increased 
in size. The use of these kind of tents has been attended 
with the very best results in the hands of MM. Beclard 
(Loc. cit.), Dupuytren (Loc, «/.), Marjolin (Loc. cit.), and 
Velpeau (Loc. cit.). The objection, however, that is urged 
against this method of distention is, that it is sometimes 
tedious and painful; the pain, however, only attends the 
introduction of the first and second tent. The tent should 
be well besmeared with the butter of cacao, or saturated 
with glycerine, and if possible, suffered to remain in twelve 
or twenty -four hours ; the patient in the mean time maintain- 
ing the recumbent or horizontal position. 



ANAL FISSURE. I3I 

Tents composed of such materials as become swollen and 
enlarged by warmth, or by the imbibition of moisture or 
fluids, might be used with advantage in the treatment of 
this disease. I employed the sponge tent in two cases with 
decided good effect, but it was attended with very severe 
pain. I consider it very certain and efficient. The second 
tent is generally sufficient, in ordinary cases, to produce 
adequate dilatation. The gent? ana radix may also be men- 
tioned for this purpose. I, however, decidedly prefer the 
bougie I have already named, in all such cases. 

Forcible Dilatation. I remember having seen a number of 
years ago, in some of the French Medical Journals, a state- 
ment of M. Maisonneuve, in which that distinguished sur- 
geon recommended and employed with success forced and in- 
stantaneous dilatation of the anus and anal canal, as a remedy 
in fissure of the anus. He performed this operation by in- 
troducing his right hand through the anus and anal canal 
up into the pouch of the rectum, then firmly clenching it 
and forcibly withdrawing the fist. I recollect, at the time, 
I was forcibly struck with the novelty, the barbarity, as well 
as the repulsive nature of the proceeding. The operation 
met with no favor, and has since been justly consigned to 
oblivion. Subsequently, however, a modification of the 
operation of M. Maisonneuve was recommended, in which 
the two thumbs were to be substituted for the fist. I am 
unable to say who had the merit of introducing this modifica- 
tion of M. Maisonneuve's operation, more than that the very 
able and distinguished French surgeon, M. Nelaton, has 
practised it for a number of years, and is its advocate ; hav- 
ing, it is said, employed it successfully in a number of cases. 

The operation as performed by M. Nelaton, the patient 
always being under the influence of an anaesthetic, is as fol- 
lows : — "The patient being conveniently placed, the two 
thumbs are introduced into the anus, and the tuberosities of 
the ischium serving as points-d? appui for the fingers, they are 



132 ANAL FISSURE. 

separated until they come in contact with the internal face 
of the tuberosities. A resistance is felt, when suddenly there 
is a feeling of an internal rupture, and the two thumbs touch 
the bones. This is sufficient. There is no dressing neces- 
sary. When the patient recovers from the effects of the 
anaesthetic he has some pains, at times quite sharp! but it is 
not like the kind of pain he felt before, it is of a differ- 
ent character ; when this pain is over, the patient does not 
suffer any more. It is sufficient during the first few days to 
administer enemata to facilitate the stools, and at the end of 
a week the patient can attend to all his occupations." — (Clin- 
ical Lectures on Surgery. From Notes taken by IV. F. Atlee, M.D. 
p. 552. Philadelphia, 1855.) 

Professor Van Buren is the advocate of forcible dilatation 
of the sphincter ani by means of the thumbs, as a prompt 
and sure remedy in anal fissure, as well as in some other 
diseases of the rectum. He prefers this method to, and sub- 
stitutes it for that of M. Boyer, objecting to the latter mere- 
ly because it is a cutting operation, and that patients dread 
the knife. The objections, however, to the process of M. 
Boyer are surely of a much more grave or serious nature 
than the patients' dread of the knife merely. Were the 
patient, however, to be made well acquainted with both 
operative procedures, and then consulted as to which he 
would choose, he might perhaps, with all his natural dread of 
cutting and of the knife, prefer the method of M. Boyer, of 
having all the fibres of the sphincter ani muscle divided 
with the knife, to the method of Dr. Van Buren, of having 
some of the fibres of this muscle torn and the remainder of 
them paralyzed by violent stretching with the thumbs. The 
question would simply be, whether the patient would pre- 
fer cutting with the knife, to tearing and paralyzing by 
forcible dilatation. Dr. Van Buren reports a number of 
cases he has cured by this process, without any bad results. 
— (Loc. citS) 



ANAL FISSURE. 1 33 

Those who approve and adopt this measure claim for it 
entire exemption from danger. I cannot, however, see why 
it should not be dangerous, as considerable violence is evi- 
dently done to the parts. Indeed the advocates themselves 
of this proceeding appear to be surprised that it should not 
be so ; yet they tell us that no accidents have occurred in 
the cases upon which they have operated. They must all 
know, however, that this operation, which is effected by 
sheer manual force, can never be performed without more 
or less laceration, tearing or rupturing of the membranes and 
vessels of the anal canal. A considerable portion of the 
muscular fibres of the external sphincter, especially, are evi- 
dently torn or ruptured in this violent stretching process, as 
witnessed in the relaxed and flabby condition of this mus- 
cle, the complete inability of the patient to control it, and 
in the fact that if the finger immediately after is introduced 
into the anus, quite a gap is felt in the substance of it. Patients 
who have been subjected to this operation, without having 
been put under the influence of an anaesthetic, invariably state 
that it is attended with dreadful pain and a sense of tearing. 
The operator himself experiences a sensation of tearing, or 
giving way of something, and the haemorrhage that imme- 
diately ensues is a positive evidence that a breach has been 
made. 

The immediate consequences of the injury thus inflicted 
by this operation, upon the integrity of the mucous and 
muscular tissues of the canal, are increased irritation and 
inflammation, and subsequently permanent contractions, an 
additional source of mischief; for as the union of the torn 
portions proceeds, the cicatrices become firm and indurated 
and tend gradually to contract, whilst at the same time the 
inflammatory action existing in the surrounding parts pro- 
duces their adhesion, and thus ultimately indurations are 
formed, involving the proper membranes of the canal in one 
common mass with the subjacent parts. Under such cir- 



134 ANAL FISSURE. 

cumstances it would not be surprising if the patient should 
at some subsequent period find himself suffering from a firm 
and hard stricture of the anus or anal canal. 

Furthermore the immediate and forcible distention, or the 
over-stretching of the external sphincter muscle in this 
operation, even without producing any laceration, might so 
far paralyze it, or impair its contractile power, that it might 
never afterwards be able to resume its function as a sphinc- 
ter. Three instances of this character, caused by this opera- 
tion, have fallen under my own observation within the last 
two years. Two were females, and one a male. They 
were all operated on by surgeons in this vicinity. I found, 
upon examination, that in each case the external sphincter 
was in a relaxed and flabby condition, having to a great extent 
lost its contractile power. In these cases, for some time after 
each fsecal dejection, small portions of faeces pass involun- 
tarily from the anus, compelling the patients to wear a T- 
bandage and fold of rag, or to wash the parts frequently, in 
order to prevent soiling the linen. It is true that these 
persons still have the control of the internal sphincter, and 
it is fortunate for them that they have. 

These are some of the objections I have to urge against 
this operation, and in my opinion they should be sufficient 
to condemn it, and to cause its rejection altogether; for if I 
believed that it was absolutely and essentially necessary that 
the whole or a part of the muscular fibres of the anal sphinc- 
ters should be divided, in order to effect a cure of anal fis- 
sure, I would decidedly prefer dividing them with the knife, 
inasmuch as a simple incised wound is, for obvious reasons, 
far more preferable than a torn, mangled, and irregular one. 
This operation, so far as my knowledge extends, is princi- 
pally confined to France, where it originated, and to our own 
country, in which it has been within a few years introduced. 
I believe it is neither adopted in England nor in Germany. 

There would not be so serious an objection to this opera- 



ANAL FISSURE. I35 

tion, if a smaller distending body than the two thumbs were 
used, and if the distending force was so controlled as to in- 
sure the membranes against laceration or rupture. I have 
myself on several occasions adopted a modification of it 
with most decided good results. Instead of the thumbs, I 
introduce into the anus the index finger of each hand, 
and forcibly dilate the contracted muscle, first, antero-pos- 
teriorly, and then laterally, at the same time taking great 
care to preserve the integrity of the membranes. 

A few years ago, I saw an instrument called an anal dila- 
tor, which worked by a screw. It was invented and intend- 
ed as a substitute for the thumbs in this operation. This 
instrument was ingeniously contrived, and beautiful to look 
at ; but it is entirely too much of an automatic machine ; it 
leaves no scope for the judgment of the operator. It is 
impossible by such an instrument to regulate the exact 
amount of dilatation necessary. The thumbs or the fingers 
as dilators are far preferable to this, as the operator, having 
the complete control of them, can regulate the force ac- 
cording to the effect. 

It is remarkable what a great thirst there is among some 
surgeons of the present day for operating by new, novel, 
and extraordinary means — such as crushing, rupturing, 
lacerating, tearing, etc. One among our able professors of 
surgery, a short time since, made the remark to a friend 
that he had rejected the knife in all the surgical operations 
in which it was heretofore used, except in lithotomy. With 
him the ecraseur is the instrument par excellence. By it he 
removes all tumors, all limbs, the uterus, the penis, the 
tongue, etc., and uses it in the operation for anal fistulse, 
etc. 

What will be the result of this ecrasement furor, or of such 
surgery % or what will come next ? are questions. 

4. Incision of the Mucous Membrane. The incision of the 
mucous membrane alone, or including with it sometimes the 



I36 ANAL FISSURE. 

submucous cellular tissue, and even some of the muscular 
fibres, in the treatment of anal fissure, has been recom- 
mended by some eminent surgeons as a substitute in certain 
cases for complete division of the anal sphincters. This 
limited operation is infinitely preferable to that of M. Boy- 
er, especially as it is said by some to fulfil every indication 
claimed for by his; as well as its being entirely free from the 
dangerous consequences so liable to follow his proceeding. 
According to the testimony of the late Sir Benjamin 
Brodie, Mr. Copeland was the first surgeon who, in anal 
fissure, advised simple incision of the mucous membrane in 
certain cases, instead of incision of the anal sphincters, as 
recommended by M. Boyer. — (Op. cit. p. 325.) Upon this 
subject Mr. Ouain says: "It is now more than fourteen 
years ago, that being about to perform Boyer's operation 
upon a female in this hospital (University College Hospital, 
London), who was lying in bed, and not held with sufficient 
firmness, having suddenly moved away, I drew the bistoury 
through the ulcerated membrane only. It occurred to me 
at the moment to ascertain if that slight incision would be 
enough to relieve the patient. The success was complete ; 
and from that period I have used no other operation in 
ordinary circumstances." In a note, Mr. Quain further re- 
marks : u At the time I thought that this method had origi- 
nated altogether with myself, but upon examining various 
books, with a view to be assured upon this point, I found 
in a lecture of Sir Benjamin Brodie's a remark which shows 
that in certain cases the modified operation had been previ- 
ously performed by another surgeon." — (Op. cit. p. 175.) 

I would here remark, that so far as priority is concerned 
with regard to this operation, I have elsewhere already 
shown that it, or a similar one, was practised and recom- 
mended by Albucasis and others of his time, and conse- 
quently is not a discovery or an invention of modern times. 
Mr. Copeland, however, has the merit of re-introducing 



ANAL FISSURE. 1 37 

and reviving it, and especially as a complete substitute for 
the formidable and obnoxious operation of M. Boyer. 

Mr. Curling is of opinion that the simple and superficial 
incision of the mucous membrane, as recommended by Mr. 
Copeland, is not sufficient to effect a cure in anal fissure. 
He says : " I am convinced that on this point Mr. Cope- 
land is in error ; at any rate this is not sufficient, and that, 
however slight and superficial the incision may be, a few 
at least of the fibres of the sphincter must be divided." 
— (Op. cit. p. 10.) 

Mr. Henry Smith, speaking on this same subject, says : 
" Thanks to the suggestion of the late Mr. Copeland, 
surgeons, whilst recognizing the same principle as influenced 
Boyer, are content with making only a limited incision, so 
as to fairly cut through the ulcer, and only divide a portion 
of the fibres of the sphincter muscle. Some surgeons even 
suppose that it is not necessary to divide any of the fibres 
of the sphincter, and simply recommend an incision 
through the ulcer ; but it must be borne in mind that a fair 
incision to the bottom of the ulcer will of necessity involve 
some portion of the sphincter. The rule I adopt and would 
recommend is to carry the incision to such an extent as 
will produce a sensible dilatation of the anal orifice. This 
is readily ascertained by introducing the finger after the 
operation. If the ulcer be fairly divided, and with it some 
of the fibres of the sphincter, the contraction of the lower 
part of the bowel will be much diminished when the finger 
is introduced, and this is a pretty certain indication that the 
necessary incision has been effected." — (Op. cit. p. 134.) 

Believing as I do that an anal fissure never invades the 
muscular coat of the rectum, I am consequently of opinion, 
that even in the worst cases it is only necessary to incise the 
mucous membrane and submucous cellular tissue to effect 
all the relief claimed for by it, namely, removing the ten- 
sion of the parts, and setting the mucous membrane at lib- 



I38 ANAL FISSURE. 

erty. I am fully convinced, however, that even this opera- 
tion is unnecessary, inasmuch as the disease can most cer- 
tainly be cured by proper topical applications, combined 
with suitable dilatation ; but I decidedly prefer it to forci- 
ble dilatation with the thumbs, which is difficult, painful, 
dangerous, and in some instances impossible. 

Modus Operandi. Previous to the performance of this 
operation the bowels should be emptied by an aperient, and 
the rectum afterwards well cleared out by an enema. The 
patient being placed on the left side, with the knees drawn 
up to the chin, the surgeon should introduce his left index 
finger, warmed and well lubricated, into the anus and anal 
canal, in the direction and beyond the upper end of the fis- 
sure. He should then introduce a straight probe-pointed 
bistoury flatwise, along and in front of the finger in ano, until 
the point has reached a little beyond the superior extremity 
of the fissure, when the bistoury should be turned round 
with its cutting edge against the ulcer. The incision is 
then to be commenced at this point, and carried through 
the fissure down to the external skin, care being taken in 
bringing down the bistoury not to cut so deep as to di- 
vide any of the fibres of the sphincter. The incision may 
be made either through the fissure, or in the immediate vi- 
cinity of it. After the incision has been made, a small 
pledget of lint besmeared with simple cerate may be press- 
ed into the wound. It is best not to allow any action of the 
bowels for two or three days after the operation. This may 
be effected by the patient maintaining the horizontal pos- 
ture, taking an enema of starch and laudanum, and strictly 
observing a milk diet. 



G. T I EM ANN k CO. 

Fig. 14. 

This operation I have performed on several occasions 
with an instrument which I devised and which is represent- 



ANAL FISSURE. I39 

ed by Fig. 14. This instrument is founded somewhat upon 
the principle of the lythotome cache, and consists of a straight 
narrow-bladed bistoury three inches and a half long, the 
blade of which is concealed by a guard having a deep slit 
in it, and which is easily adjusted to the blade, and rests 
upon two pivots, one on each side of the same. The distal 
extremity of the guard is blunt, and its proximal extremity 
terminates in a steel spring which rests upon the back of 
the handle of the blade. By pressing upon the handle of the 
bistoury when it is properly adj usted upon whatever is intended 
to be cut, a portion of the cutting edge of the blade leaves 
the slit of the guard, and is made to appear. This instru- 
ment, being small, is easily introduced into the canal without 
the finger. It should be warmed, well lubricated, and insert- 
ed into the canal in the direction of the fissure and a little 
beyond its superior extremity, with the slit in the guard 
facing the fissure or ulcer ; then pressing upon the handle, 
the blade will appear, and the instrument thus drawn out 
will make the incision of the mucous membrane only, as 
the guard is so arranged that the blade cannot cut deeper 
than this tissue. 

5. Excision of the Fissure. The operation of excising the 
fissure instead of dividing the anal sphincters, I believe was 
first proposed and executed by M. Velpeau. In this opera- 
tion the integrity of the muscular coat is preserved, neither 
the muscle nor the muscular fibres being interfered with. 
M.. Velpeau performed this operation in eight or ten cases, 
in two of which the fissure reappeared and was never cured. 
He, however, recommended, in very obstinate cases, the 
combination of the two methods — that is, both the division 
of the anal sphincters, and the excision or extirpation of the 
fissure or diseased part. Care should be taken, in perform- 
ing the operation, to remove the whole affected portion. 

The operation of excision of the fissure, as performed by 
M. Velpeau, is as follows : The patient being placed in the 



140 ANAL FISSURE. 

same position as that for incision of the sphincters, the 
surgeon seizes with a tenaculum the point of the verge of 
the anus occupied by the fissure, and with a few strokes of 
the bistoury, on the right and the left, completes the exci- 
sion of the fissured part. The scissors may be employed 
to remove the fissured or diseased part, but care must be 
taken to avoid cutting the muscular tissue beneath. The 
operation is soon done, and attended with but little pain. 
The wound requires to be dressed for three or four days, 
and the bowels prevented from acting, as recommended in 
the operation of simple incision of the mucous membrane. 
— (Demonge, France Medicate, Home I. p. 46. Also Motfs 
Felpeau, Vol. III. p. 1115. New Tori, 1847.) 

6. Myotomy of the Anal Sphincters. The merit of first recom- 
mending and executing the operation of dividing the anal 
sphincters, in fissure of the anus, is universally attributed 
to M. Boyer. I have elsewhere shown, however, that it was 
advised by Ambrose Pare. Be this as it may, M. Boyer 
was nevertheless the first surgeon who, in modern times, 
executed it, and gave it a status in surgery as a powerful 
remedy in anal fissure. 

The operation, as I have elsewhere observed, is founded 
upon a mere hypothesis. The anal spasm for which the 
operation is advised is only a symptom, an effect, or a result 
of the fissure, which is the real disease. The operation 
being wrong in principle and most mischievous in 
practice, cannot therefore be approved of upon rational 
grounds. All treatment is irrational that is not directed to 
the morbid condition of the mucous membrane of the part, 
or that does not immediately tend to heal the fissure, the 
real disease. It must not be taken for granted that because 
the operation removes, for the time being, the muscular 
spasm, that this spasmodic contraction is the real disease or 
cause of it. At best the operation can only be of service 
as a temporary amelioration of the real disease. 



ANAL FISSURE. I4I 

M. Boyer considered this operation as an infallible remedy 
in the treatment of anal fissure, yet several most eminent 
surgeons have reported cases in which it has utterly failed. 
Among such are MM. Velpeau, Recamier, Beclard, etc. 
M. Velpeau says of this operation, that it compels us to cut 
through the deeper-seated tissues beyond the muscles. The 
wound which results always suppurates for some time, and 
may occasion dangerous accidents. The inflammation and 
formation of matter may extend to the pelvis, and com- 
promise the patient's life. I have seen two cases, says he, in 
which the patients died after a division of the sphincter, for 
fissure of the anus. — (Loc. cit.) 

Inflammation from this operation is liable to be produced, 
and extend to the loose cellular tissue immediately external 
to the muscular tissue ; from this it may extend to the cellu- 
lar tissue external to the peritonaeum, and terminate in the 
destruction of the patient. In consequence of the peculiar 
anatomical structure of the parts in females, the operation is 
always hazardous. By this operation, too, the patient is 
often rendered permanently incapable of retaining either the 
intestinal gases or his stools, and they pass involuntarily. 
This truly would be a most deplorable condition to be left 
in, even if cured of the anal fissure. The operation, too, is 
by no means free from serious, if not fatal haemorrhage. 
I therefore consider the operation unscientific in principle, 
as well as uncertain and unsafe in practice ; but, for the 
benefit of those who may think and practise otherwise, I 
will give in full the modus operandi of it, together with a few 
modifications of it, and conclude with the observation, 
that to avoid the use of the knife, if possible, in the treat- 
ment of this disease, should be the rule of the well-edu- 
cated and scientific surgeon, both in public and in private 
practice. 

The Proceeding of M. Boyer. The preparatory steps of 
Boyer's operation are precisely the same as those for inci- 



142 ANAL FISSURE. 

sion of the mucous membrane in the same disease. A day 
or two previous to the operation, the bowels should be 
emptied by means of a mild purgative, and on the day of 
the operation the rectum should be completely cleared out 
by an enema, in order to insure entire quietude for several 
days after. An injection of thin starch and laudanum should 
be administered immediately after the operation, and the 
patient should maintain the horizontal posture, and observe 
a milk or meagre diet, so that he may remain free from any 
faecal evacuation for four or five days. 



t i em ann & co. 
Fig. 15. 

The instruments employed are a straight blunt-pointed 
bistoury, the blade two inches long and about one sixth of 
an inch wide (Fig. 15) ; a common bistoury, a large tent 
made of lint, a T-bandage, and all the minor accessories. 
The patient being placed on his left side, on the edge of a 
bed, with his head low, the under limb extended, the upper 
one flexed, and the nates widely separated by assistants, the 
surgeon, after anaesthesia is produced, should introduce the 
index finger of his left hand, well lubricated with cerate, in- 
to the rectum, and gliding along it the flat side of the blunt- 
pointed bistoury to a little beyond the superior end of the 
fissure, the cutting edge should then be turned towards the 
surface of the canal in the course of the fissure, if it be sit- 
uated laterally, and the coats of the intestine, the anal 
sphincters, and the surrounding cellular tissue and integu- 
ment should be divided by one stroke of the bistoury. A 
triangular wound is thus made, the summit of which answers 
to the intestine and the base to the skin. Should it be 
necessary to extend the external incision, as it sometimes 
is, it can be done by an additional stroke of the bistoury. 
In some instances the intestine slides before the edge 



ANAL FISSURE. 



H3 



of the knife, and the wound of the cellular tissue is then 
larger than that of the intestine. Should this occur, it will 
then be necessary to re-introduce the bistoury, in order to 
prolong the wound of the intestine ; or this may be accom- 
plished by a blunt-pointed scissors. Should there be a fis- 
sure on each side, or should there be excessive spasmodic 
contraction of the sphincter or sphincters of the anus, both 
sides must be incised alike. The incision should always be 
made through the fissure, provided it is located on one or 
the other side ; but if it is situated in front or behind, the 
incision of the side is quite sufficient. No operation of the 
kind should ever be made either anteriorly or posteriorly, 
because the anal sphincters can neither be safely nor com- 
pletely divided at either of these points, on account of the 
shortness of the space between the coccyx and the verge of 
the anus, the proximity of the bulb of the urethra in the 
male and the shortness of the perinseum in the female. 
Another serious objection to the performance of this opera- 
tion in the median line, is the great difficulty in healing 
wounds in this situation, in consequence of the friction cre- 
ated by the motion of the extremities. 

Should the edges of the fissure be hard and elevated, 
they should be seized with a forceps and removed. Should 
haemorrhage occur, the usual measures for arresting it must 
be promptly put into practice. The dressing of the wound 
is very simple. Dossils of lint covered with cerate should 
be placed between the lips of the wound, and extend about 
an inch beyond the superior angle of the incision. The 
space between the nates should be filled with lint, and the 
whole supported by a compress and a T-bandage. In 
four or five days the dressing should be carefully removed, 
and after that it should be daily renewed until cicatrization 
takes place. The wound is generally cicatrized in about 
one month or six weeks ; sometimes, however, the healing 
is not effected under two or three months. 



144 ANAL FISSURE. 

I would observe here that M. Boyer did not consider it 
essentially necessary to the success of the operation that the 
incision should be made immediately through the fissure. — 
{hoc. cit?) M. Velpeau, however, thought differently. He 
says : " Should the fissure occupy the median line in front, 
the surgeon must not cut upwards, for fear of injuring the 
urethra or the vagina. Boyer thought it sufficient to di- 
vide the sphincter at any point without caring where the fis- 
sure may be located ; but I am of opinion that the surgeon 
will do well to pass the blade of the bistoury through the 
fissure at the same time that the muscle is divided." — (Loc. 
cit?) 

tfke Proceeding of Boyer as modified by Blandin. To avoid 
the dangers, uncertainties, and the inconveniences of Boyer's 
operation, M. Blandin devised, executed, and recommended 
a modification of it, consisting of the submucous and sub- 
cutaneous section of the sphincter ani. Blandin's operation 
is very ingenious ; it is simple, and far less formidable and 
repulsive to the feelings of the patient, and certainly, in a 
practical point of view, attended with much less risk. The 
relief is as instantaneous as it is by Boyer's operation, and 
no large open wound is left in the intestine, the intestinal 
membrane and integument being entire. Defecation can 
therefore be performed without the same amount of irrita- 
tion; and the cure is materially expedited, inasmuch as 
the parts are not kept in a state of disunion longer than is 
necessary for its completion. 

In this operation the same preliminary treatment with 
regard to unloading the bowels is as necessary as in that of 
Boyer, and the precautions concerning the impropriety of 
incising directly forwards in the female, or directly back- 
wards in either sex, are equally applicable to both methods 
of operating. The instrument employed for operating by 
the method of Blandin consists of a sharp-pointed straight- 
bladed bistoury, with a flat sliding guard upon one side of 



ANAL FISSURE. 145 

it. This guard is rounded at the extremity, oval externally, 
and flat upon the surface lying on the blade. It is com- 
pressed against the side of the knife by means of a spring, 
and retained in its position by a slightly projecting pin, 
sliding in a groove upon the blade. The whole, or a por- 
tion, of the guard can be retracted within the handle by a 
button attached to it for that purpose. This instrument, a 
little simplified and improved by myself, is represented by 
Fig. 16. 



TIEMANN-CO 

Fig. 16. 

The patient being placed in the proper position, a small 
puncture with the point of the bistoury is then to be made 
in the skin, at the distance of from eight to ten lines from 
the verge of the anus. The index-finger of the left hand 
is now to be introduced into the rectum, in order to keep 
the mucous membrane tense, at the same time the skin on 
each side of the anus being well stretched by an assistant. 
The guard is protruded beyond the point of the blade, and 
the tenotome is then carefully introduced through the wound 
and passed up between the mucous membrane and the 
sphincter to the requisite height. The cutting edge is then 
turned towards the sphincter, the guard retracted, and the 
muscle cut through as the blade is withdrawn. As soon as 
the section of it is made,- the finger in the rectum feels the 
solution of continuity between the divided portions of the 
muscle, which is preceded by a peculiar noise — "une espece 
de craqiiement." ' If any doubt remains as to whether the 
muscle is completely divided or not, the tenotome, guarded 
as before, may be reintroduced, and a second incision made 
in a similar manner, exactly upon the first. The small ex- 
ternal wound should then be closed. The after-dressings 
should consist either of lint covered with simple cerate, or. 

10 



I46 ANAL FISSURE. 

lint wet with a cooling lotion, or simply cold water. The 
bowels should be kept in a relaxed state by mild purgatives, 
or by enemata alone. A double submucous section of the 
sphincter may be made if necessary, — one on each side. 

M. Blandin has performed this operation with complete 
success in several cases of anal fissure. M. Marchal (de 
Calvi) also performed the same operation on a man suffering 
from cancer of the rectum, attended with painful spasmodic 
contraction of the anus. This patient suffered intense 
agony after each evacuation of the bowels. The operation 
at once afforded great relief. — {Archives Generates de Medecine 
de Paris, Avril, 1846.) 

tfhe Proceeding of Boyer as modified by Dr. Hayward. — The 
late and lamented Dr. Hayward of Boston, late surgeon to 
the Massachusetts General Hospital, was of opinion that no 
treatment short of Boyer's operation of the division of the 
anal sphincters would be effectual in relieving anal fissure. 
He reports a successful case of fissure of the anus in which 
he divided the muscles from without inwards, instead of from 
within outwards, as in the operation for complete fistula in 
ano. This he considered the best method. A part of this 
case he relates as follows : — " On examination, I found just 
within the margin of the anus, towards the sacrum, a narrow 
ulcer an inch or more in length, quite tender and painful to 
the touch. The bowels having been emptied by an enema, 
the operation was performed in the following way: The 
forefinger of the left hand having; -been introduced into the 
rectum, a spear-pointed scalpel was thrust in outside of the 
sphincter till it reached the point of the finger, thus includ- 
ing the sphincter between the edge of the scalpel and the 
finger. Both were then simultaneously withdrawn, the 
scalpel cutting its way out through the fissure. Lint was 
introduced between the lips of the wound, and a compress 
and a T-bandage completed the dressing. For two or three 
. days he had slight spasms about the anus, which were re- 



ANAL FISSURE. I47 

lieved by anodyne fomentations. But after this period he 
had no trouble; his dejections gave him no pain, though 
the ulcer was not healed, and he was discharged from the 
Hospital " well " in fourteen days after the operation, in all 
respects able to resume his ordinary avocations." — {Report of 
the Surgical Cases that occurred in the Massachusetts General 
Hospital from \2th May, 1837, to 12th May, 1838.) 



CHAPTER SIXTH. 



CONCLUSION. 



CHAPTER VI. 

CONCLUSION. 
Section I. — Illustrative Cases. 

The following cases of anal fissure, selected promiscuously 
from my case-book out of a large number collected during 
a practice of thirty years, will illustrate the several phases, as 
well as the complications under which this disease generally 
presents itself: 

Case I. — Anal fissure of nine months' standing, caused by obsti- 
nate constipation of the bowels, and the continued use of drastic 
purgatives. 

On the nth of September, 1840, Miss S. T- , 

of Jessamine county, Kentucky, set. twenty-six, a very 
delicate lady of a nervous temperament, consulted me for a 
disease she had suffered from for nine months, and which 
her physician, who had frequently examined her, pronounc- 
ed to be constipation and internal piles, caused by torpor of 
the liver. To relieve the torpor and the constipation, he 
was in the habit of giving her an active cathartic about 
twice a week for a long time. She could only tell me the 
name of one of the several kinds of drastic purgatives she 
had been taking, and that was " Cool's Ptlls" a quite com- 
mon medicine of that day, composed of equal parts of aloes, 
rhubarb, and calomel. She gradually grew worse under this 
active treatment, which seemed to have changed the charac- 
ter of the disease altogether — so much so, that she finally de- 
termined to abandon both the treatment and the doctor. 

She informed me that for the last three months she had 



152 ANAL FISSURE. 

suffered the most intense burning and lancinating pains in 
the anus whilst stooling, and for three or four hours after, 
often attended with most violent spasms of the sphincter ani. 
All these symptoms were much aggravated during menstrua- 
tion, which was generally quite normal. She had a great 
dread of stooling, and to avoid it as much as possible, she 
would almost starve herself, so that she had become quite 
emaciated. The stools, when hard, were generally streaked 
with mucus tinged with blood; and when soft, were figured 
and of small size. 

Upon making an examination, by divaricating the nates, 
I observed on the left side of the anus a lineal ulcer com- 
mencing at the verge of the anus, and extending up into the 
canal about three-fourths of an inch. This crevice was so 
deep as to extend through the mucous membrane ; it pre- 
sented a bright red appearance, and its edges were hard and 
elevated. I could not insert my finger into the anus in 
consequence of the rigidity of the sphincter, and the severe 
pain occasioned by pressing on and separating the lips of 
the fissure. To overcome the spasmodic contraction of the 
sphincter, I administered as an enema one ounce and a half 
of an infusion of belladonna, and two hours after repeated 
the same ; in the meantime the anus was well fomented with 
cloths wrung out of hot water. The infusion was prepared 
as follows : 

Recipe, Belladonnas Radicis, drachmam, 

Aquas bullientis, uncias sex. 
Misce et fiat infusum, macerando horam integram : dein cola. 

By these measures I was enabled in about four hours to 
introduce my finger into the rectum with ease, and with 
scarcely any pain, as well as a bougie much larger than the 
finger. 

This patient was kept in the horizontal position ; took a 
mild tonic; her diet was chiefly animal broths, rice, arrow- 
root, etc. ; no cathartic medicine whatever was given, her 



ANAL FISSURE. 153 

bowels being entirely relieved every alternate day by an 
enema composed of the infusion of linseed and castor oil. 
The edges of the fissure were touched with the solid nitrate 
of silver on the days on which the bowels were not evacu- 
ated, and immediately after each application a small pledget 
of lint besmeared with the simple ointment of belladonna 
was inserted. The first application caused very severe pain, 
which continued for three or four hours. The two follow- 
ing applications were not so severe. The solution of the 
salt was now substituted for the caustic in its solid form. It 
was applied to the fissure every day, and the bougie was 
used immediately after. At the end of the second week 
an evacuation took place daily, always preceded, however, 
by the enema ; about two hours after which, the application 
would be made, and the bougie inserted' for a moment. 
Under this treatment the fissure completely cicatrized in 
four weeks. This patient returned home completely re- 
lieved of the fissure and the constipation. 



Case II. — Hhe lady referred to in the following communication 
was successfully treated by me for an anal fissure, complicated 
with hemorrhoids, six months after the date of the letter. 

" , Ky., September 8th, 1841. 

" Dr. Bodenhamer : 

" Dear Sir — My wife is afflicted with a 
serious disease of the lower bowel, for which she has taken 
much medicine from several physicians, without any per- 
manent good effect. Indeed, they do not appear to under- 
stand her disease. Her physicians all have advised her to 

consult Dr. D , believing that some surgical operation 

might perhaps be necessary. We have come to the con- 
clusion, before taking this step, to consult you ; and if you 
think that you can cure her, we will visit you as soon as we 
get your answer to this. For several years my wife labored 



154 ANAL FISSURE. 

under costive bowels, for the relief of which she was 
compelled, from time to time, to take active purgative 
medicine. About seven months ago, one day after she had 
taken a large dose of Cook's Pills, which operated severely, 
she was taken with such a burning pain while at stool, that 
she nearly fainted. Ever since, whenever she stools, and 
for hours after, she suffers the most agonizing pain. These 
pains extend to her back and down her lower extremities, 
and sometimes so affect her bladder that she cannot urinate 
without great difficulty. Her discharges from her bowels 
are frequently mixed with blood and matter ; and when she 
has these discharges, the burning is just like hot lead pass- 
ing down her bowels, as she describes it. She is nearly all 
the time confined to her bed, a mere skeleton, and so ner- 
vous at times that we can scarcely do anything with her. 
Such is the dread she has of an operation on her bowels, 
that she frequently sheds tears for an hour or two previous. 
She has no cough, and her digestion is good ; and if she were 
relieved of this horrid disease, she would, I think, be well 
otherwise. Some of her physicians call her disease fistula, 
and others piles. She has had three children, the youngest 
two years old, and her age is thirty." 

On making an examination of this case, I found on each 
side of the anal canal posteriorly, a hsemorrhoidal tumor 
about the size of a hazel-nut, which I caused the patient to 
protrude as much as possible, when I detected a long narrow 
ulcer between the two tumors at the posterior verge of the 
anus, and extending into the canal about two-thirds of an 
inch. Its edges were thick and hard, and its surface florid, 
and bled freely when touched with the probe. The at- 
tempt to introduce the finger gave excessive pain, and 
brought on a violent spasmodic contraction of the sphincter. 

This lady continued to maintain the horizontal posture ; 
took as a tonic the muriated tincture of iron and the cold 
infusion of wild-cherry bark ; lived on nutritious broths, 



ANAL FISSURE. 155 

jellies, etc.; and relieved her bowels entirely by emollient 
enemata. The fissure was touched several times with the 
solid nitrate of silver, afterwards the solution of the same 
was substituted. The bougie was also frequently used. 
After pursuing this course for two weeks, and the fissure 
having greatly improved, the hsemorrhoidal tumors were 
then removed by ligature, and the cure completed in two 
months from the commencement of the treatment. 

Case III. — Anal fissure complicated with a small blind in- 
ternal fistula. Tfe patient had been treated several months 
for irritable piles, the true nature of the case not having been 
understood by the medical attendants. 

On the 10th of October, 1844, I was called to see Mr. 

S. P. W , a commission merchant of Louisville, Ky., 

set. 45, of a bilious and nervous temperament. This gentle- 
man, for several months previous to consulting me, suffered 
the most violent and agonizing pain in the anus after each 
evacuation of the bowels; the pain coming on regularly 
from within thirty minutes to an hour after each stool, and 
continuing from eight to twelve hours, when it would 
gradually, and sometimes suddenly, cease. Such was Mr. 

W 's sufferings, that after having an evacuation of 

his bowels in the morning, he was compelled to remain on 
his couch all day; and the only time that he could be up 
and attend to business at all, was in the morning, an hour or 
two before stooling. 

From the commencement of his illness, Mr. W. had sub- 
mitted to both medical and surgical treatment; one or two 
hsemorrhoidal excrescences at the verge of the anus had been 
removed, with, however, no mitigation whatever of the 
usual and regular pain. The primary disease having been 
mistaken for haemorrhoids, was entirely overlooked by his 
medical attendants. Mr. W. informed me that some con- 
siderable time previous to the commencement of his present 
suffering, he suffered from indigestion and obstinate consti- 



I56 ANAL FISSURE. 

pation of the bowels, for the alleviation of which he had 
taken large quantities of drastic purgative medicine, and also 
various tonics, etc. 

On examining the anus externally, I saw the remains of 
the principal anal excrescence which had been removed, 
situated on the posterior margin of the anus, on the left side. 
By making firm pressure with the finger on this part, great 
pain was experienced, and violent anal spasm was induced. 
I also noticed that the pressure caused a slight oozing out 
of pus at this point. Such were the pain and the rigidity of 
the sphincter, that the attempts to evert the anus, or to in- 
troduce the finger, were fruitless ; consequently I adminis- 
tered an enema of warm flax-seed tea and castor oil, and 
completely emptied the rectum, and applied to the anus 
cloths wrung out of hot water for one hour, after which I 
succeeded, although attended with considerable pain, in in- 
serting my finger up to the second joint, and sensibly felt a 
fissure running up the canal from the tender point already 
noticed. After withdrawing the finger, I carefully intro- 
duced a small speculum ani, which completely revealed the 
whole extent of the fissure, which was nearly one inch in 
length, from the centre of which I discovered a small orifice 
from which issued a little matter. By using a hooked probe 
I discovered that the orifice communicated with a small fistu- 
lous cavity — quite superficial, however. The cause of Mr. 

W 's suffering was now clearly explained. The fistula, 

doubtless, was caused by the fissure. 

The treatment consisted of enemata composed of the in- 
fusion of flax-seed and castor oil, to relieve the bowels; the 
daily application to the fissure of the solution of nitrate of 
silver ; and the frequent touching of the bottom of the fis- 
tulous cavity with the end of the bent probe, previously 
thickly coated by being dipped in the fused nitrate of silver. 
By this treatment this gentleman was completely cured in 
five weeks from its commencement. 



ANAL FISSURE. 1 57 

Case IV. — I'he author of the following letter, three months after 
its date, was cured by me of an anal fissure of an aggravated 
character. 

" C , Ohio, June 5th, 1845. 

" Dr. Bodenhamer : 

" Dear Sir — Having heard that you have 
been successful in treating diseases of the lower bowel, I 
have taken the liberty of writing you. I have been suffer- 
ing almost martyrdom for the last year, from a most trouble- 
some and distressing affection of my lower bowel. I ex- 
perience the greatest suffering while I am stooling, and 
then it is often so severe that I am compelled to lie down 
for several hours. At these times the burning and smarting 
are so severe, that it appears to me it could not be any 
worse if a red-hot iron was run into the bowel. I have 
such a horror of stooling, that I only have a passage every 
forty-eight hours, at night, so that I do not lose so much 
time in the day, by lying down. I use Blue Lick water to 
keep my bowels loose. The sore place is on the right side 
of the anus, communicating low down, and extending, up 
about an inch. I can feel it quite distinctly with my finger 
the introduction of which, however, causes the most intense 
pain. The only discharge I have noticed from the place 
is a little matter streaked with blood. I have no doubt 
this disease was caused by obstinate constipation, under 
which I labored for years, and for which I have taken large 
quantities of purgative medicines. 

" The disease did not come on suddenly, but gradually. I 
am thirty-one years of age, my health good in other respects, 
and I am by profession a lawyer. You will now doubtless 
wonder what I did for my complaint. I have done every- 
thing. I have consulted the best medical men of your pro. 
fession, and they all have disagreed with regard to my dis- 
ease, some calling it internal fistula, some piles, some neu- 
ralgia, and some ulceration. About six months ago I sub. 



I58 ANAL FISSURE. 

mitted to the operation of laying all the parts open with the 

knife, by Dr. of - m This operation afforded 

me partial relief for about six weeks ; but I am now about 
as bad as ever. I have lost all hope, and almost despair 
of ever being cured. I would much rather be dead than be 
compelled to live in this condition. Can you cure me ? 
Can you give me any relief?" 

This gentleman visited me at Louisville, Ky., on the 25th 
of June, 1845; and upon making an examination of the 
anus, nothing was visible but a large condyloma situated on 
the verge of the anus, on the right side posteriorly. This 
excrescence formed the base, and concealed the inferior ex- 
tremity of a fissure a quarter of an inch wide, and extending 
up the canal fully one inch. By everting the anus, almost 
the whole of the fissure was brought into view; its surface 
was discovered to be smooth and florid, and its edges were 
raised and hard. The division of both sphincters of the 
anus, to which he had submitted, was not made through the 
fissure, but on the side in its immediate vicinity. The in- 
cision was but partially cicatrized. 

By the use of the nitrate of silver, the employment of 
the bougie, and the removal of the condyloma with the 
scissors, the cure was completed in eight weeks. 

Case V. — Anal fissure in a little boy three years old who had ob- 
stinate constipation of the bowels, the result of inactivity of 
the liver induced by intermittent fever. Hypertrophy of the 
spleen. 

On the 8th of May, 1847, I was called to see Edward 

S , of Louisville, Ky., set. three years and two months, 

a very delicate, nervous, and excitable little boy. He was 
emaciated, had torpid liver, no appetite, skin dry and sal- 
low, and obstinate constipation of the bowels. The little 
patient the year previous had an attack of intermittent 
fever, which lasted for several weeks, and has now decided 



ANAL FISSURE. I59 

hypertrophy of the spleen, which is very apparent through 
the anterior abdominal wall. Suffers severe pain at each 
evacuation of the bowels, and for a short time after, as mani- 
fested by his sharp cries, and the strong tendency to convul- 
sions. His stools are scybalous, and always followed by five 
or six drops of florid blood. 

On making the examination of the anal region, I found 
the anus spasmodically contracted, and upon widely separ- 
ating the nates and the sides of the anus, I distinctly saw, 
at its verge, on the right side posteriorly, the inferior ex- 
tremity of a rent having the appearance of a red line, and 
observing a vertical direction, which upon close inspection 
proved to be a superficial fissure of the mucous membrane. 
This crevice was doubtless the result of a laceration induced 
by the passage of scybala. 

The little patient's bowels were daily relieved by emol- 
lient enemata, and an occasional dose of castor-oil. He took 
as an alterative tonic the third of a teaspoonful, three times 
daily, of the following mixture : 

Recipe, Syrupi Sarsaparillse compositi, uncias octo, 

Ferri Sulphatis, grana duodecim, 

Tincturas Cinchonae, unciam. 
Fiat Mistura. 

The fissure was touched once daily with the nitrate of 
silver in solution, applied with the probe. By this treat- 
ment the fissure was completely cicatrized in ten days, and 
at the end of two months the little boy was almost entirely 
restored to his wonted health. 

Case VI. — Anal fissure complicated -with fistula in ano, s per ma- 
torrhcea, and ascarides of the rectum. 

Mr. W. S. T , of Greencastle, Indiana, set. 32, of a 

nervous temperament, visited and consulted me at Louis- 
ville, Ky., on the 1 6th of June, 1847. Mr. T. informed me 
that for three or four years he suffered from indigestion 



l6o ANAL FISSURE. 

constipation of the bowels, intolerable itching of the anus, 
especially at night, and frequent nocturnal emissions of se- 
men. His stools were small and hard like marbles, and 
covered with an inspissated mucus, like skin. For the last 
three months he says that whenever he has an evacuation 
of his bowels, and for several hours after, he suffers the most 
severe and agonizing pain in the anus and anal region, and 
often accompanied by a violent and painful closure of the 
anus; and 'that within the last six weeks an abscess formed 
on the left side of the anus, which was lanced by his medi- 
cal attendant, and lately pronounced to be a complete fis- 
tula in ano. 

This patient, from this complication of diseases, was very 
much emaciated, sallow, highly nervous and excitable, as any 
one can well imagine. Upon examination, I observed on the 
left side of the anus the external orifice of a fistulous sinus 
about half an inch from the verge of the anus, which com- 
municated with the bowel between the two sphincters. In 
attempting to introduce my finger into the anus and anal 
canal, in order to search for the end of the probe which was 
in the sinus, it encountered considerable difficulty from the 
firm contraction of the sphincter muscle ; and was attended 
by severe pain. By withdrawing the finger and everting the 
anus, I detected a small superficial ulcer in the form of a 
fissure at the anterior commissure of the anus, commenc- 
ing immediately within the anal orifice, and extending up 
about two-thirds of an inch. This patient took as a tonic 
the muriated tincture of iron; regulated his bowels by mild 
cathartics and emollient enemata. The fissure and the anal 
spasm were treated by the nitrate of silver and the bougie. 
The anal fistula was treated by the use of the ligature. Mr. 
T.'s health at the beginning commenced improving slowly 
but decidedly, and at the end of three months I discharged 
him cured. I would observe that in the early part of the 
treatment of this case, for the purpose of removing the 



ANAL FISSURE. l6l 

chronic irritation and inflammation of the mucous mem- 
brane of the inferior extremity of the rectum, I ordered the 
patient to inject two tablespoonfuls of the following mix- 
ture immediately after each fsecal dejection, and if possible 
to be retained : — 

Recipe, Balsami Copaibae, 

Tincturas Opii, ana, drachmam, 

Creasotis, semidrachmam, 

Pulveris Acacias, semiunciam, 

Aquas destillatae, uncias octo. 
Fiat mistura secundum artem. 

About two hours after the injection of the first dose of this 
mixture, the patient felt so strong a desire to stool that he 
could not resist it, and he passed into the chamber without 
effort three balls of what he thought were fsecal matter, but 
upon inspection he found them entirely composed of small 
worms and mucus. He at once called my attention to the 
circumstance, and upon examining the contents of the vessel 
I found them as he had described. The worms were the 
maw or thread-worm, — Oxyuris vermicularis of Bremser, or 
the Ascaris vermicularis. These worms are generally found 
en troupe in the rectum, and so covered with mucus as not 
to be easily accessible by anthelmintics. In this instance 
the creasote in the injection was doubtless the principal 
agent in effecting their dislodgment. When counted by 
the patient, he found they numbered three hundred and 
fifty-four. • 

The continued excitement and irritation of the mucous 
membrane of the rectum produced by the presence of these 
worms in this case, were doubtless the cause of the sperma- 
torrhoea, and may have, been the predisposing cause of the 
fissure and the fistula. 

Case VII. Anal fissure complicated with a blind internal 

fistula. 

Mr. G. B. W- , a merchant of Buffalo, N. Y., set. 

11 



l62 ANAL FISSURE. 

fifty-eight, of a bilious and nervous temperament, visited 
and consulted me at Louisville, Ky., on the 9th of May, 
1849. He informed me that for six or seven months he has 
suffered the most severe burning pain in the anus, commenc- 
ing a short time after each evacuation of his bowels, and 
continuing for several hours without intermission, and then 
entirely subsiding until the next movement of his bowels. 
These paroxysms of pain were often attended with violent 
spasmodic contraction of the anus. His bowels were 
naturally inclined to constipation, and often required the 
most active purgative to move them. He has noticed of 
late a slight but constant discharge of a thin matter from the 
anus, sufficient to soil his linen; sometimes this matter was 
mixed with blood and mucus. 

Mr. W.'s general health is poor; he is quite emaciated, 
is easily fatigued, and suffers much from weakness of the 
back and lower extremities, especially for a few hours after 
evacuating his bowels, when it amounts almost to complete 
prostration. 

This gentleman had been treated for ulceration of the 
rectum by caustic applications, and a solution of the nitrate 
of silver was used as an injection, with, however, no per- 
manent benefit. Upon making an examination of the anus, 
I discovered a condyloma about as large as a common size 
pea, situated on the verge of the anus, on the right side 
towards the front. Pressure upon this part detected consid- 
erable hardness for some distance round, caused much pain, 
and a discharge of pus from the anus. By the straining 
efforts of the patient, and the everting or prolapsing of the 
anus with the fingers, a fissure was plainly visible, commenc- 
ing a little above the condyloma, and extending up the 
bowel three-fourths of an inch. It was about the eighth of 
an inch wide, with hard and everted edges, and a red, soft, 
and spongy bottom, from which some pus was seen to be 
issuing. This discharge of pus and the external hardness 



ANAL FISSURE. 163 

were plain indications of a blind internal fistula. By means 
of a bent probe, I at once found the orifice of the fistula 
just in the track of the fissure, and near its superior extremi- 
ty. I gave a flexible probe the proper curve, and through 
the orifice of the fistula conducted it from above down- 
wards and outwards, until the end could be distinctly felt 
through the external integument, about half an inch below 
the condyloma. At this point I made an incision upon the 
end of the probe into the fistulous cul-de-sac, and thus con- 
verted the blind and incomplete, into the complete fistula. 
The diagnosis was plain. The fistula in this instance was 
doubtless the result of the fissure. 

This gentleman took tonics, regulated his liver and bow- 
els by diet, emollient enemata, and occasional aperients 
Daily applications of the nitrate of silver were made to the 
fissure until the acute sensibility and the severe pain had 
subsided, when a ligature was introduced into the fistula and 
daily tightened until it came out, leaving but a small por- 
tion of the fissure and fistula to cicatrize, which soon after 
took place. Fie was dismissed cured on the 25th day of 
June, just forty-six days after the treatment had been com- 
menced. This patient was not confined for one moment to 
either his room or his bed by the treatment. 

Case VIII. — Highly irritable ulcer, situated in the fossa between 
the external and internal sphincter of the anus. 

Colonel J. W , of Woodford county, Kentucky, set. 

sixty-seven, of phlegmatic temperament, consulted me at 
New Orleans, Louisiana, on the sixth of April, 1850, for what 
he called a painful affection of the lower bowel. The 
Colonel informed me that for more than a year he has been 
suffering most severely from a burning, throbbing, and bear- 
ing-down pain, seemingly but a short distance above the 
end of the bowel. The pain would come on either whilst 
at stool or in a short time after, and continue for several 



164 ANAL FISSURE. 

hours, often extending to the neck of the bladder, and 
causing more or less stoppage of urine, and always at- 
tended by a slight purulent discharge from the anus, quite 
sufficient to soil his linen daily. His digestion and appe- 
tite are good, and his bowels are regular, but from having 
been robust and healthy at his time of life, this painful 
affection has reduced him greatly in flesh, and rendered him 
feeble, highly nervous, and excitable. 

The rectum having been thoroughly emptied by a proper 
enema, and there being no spasmodic contraction of the 
sphincter ani, the exploration was made by the finger and 
the speculum with ease and with but little pain. The fin- 
ger in aiio soon detected a large, deep, and highly sensitive 
ulcer, situated on the anterior wall of the anal canal, be- 
tween the external and internal sphincter of the anus. The 
sensation communicated to the finger was that of having 
entered a considerable excavation, with a hard and rough 
brim, and a deep and soft bottom. Upon the introduction 
of the speculum this ulcer was fairly brought into view. 
It proved to be of an oblong shape and somewhat larger 
than a silver ten-cent piece ; it was of an ash color, and 
its bottom was soft and spongy, and covered with a tena- 
cious matter. 

The ulcer was cauterized every fifth day w T ith the solid 
nitrate of silver, and in the mean time the bowels were daily 
moved by emollient enemata. Two tablespoonfuls of the bal- 
samic mixture mentioned in Case vi. (page 161) was injected 
into the rectum twice daily, first in the morning, after stool- 
ing and dressing the ulcer, again at night, just before retiring. 
During the treatment the Colonel was allowed a nourishing 
diet, and the liberal use of good sherry. 

By pursuing this course for six weeks the ulcer w T as 
cicatrized, the pains had all ceased, and the Colonel had 
greatly improved in flesh, in strength, and in spirits. 



ANAL FISSURE. 165 

Case IX. — Irritable ulcer of the rectum simulating uterine disease, 
and a large accumulation of hard and impacted faces in the 
left colon, simulating a tumor in that region. 

Mrs. J. D , of Oldham county, Kentucky, set. 

thirty-seven, of a nervous and bilious temperament, and 
mother of one child, consulted me on the 23d of May, 
1850. She stated that she had been treated a long time 
for a uterine disease, without, however, any mitigation of 
her sufferings. She also informed me that she suffered from 
indigestion, and sometimes from great irritability of the 
stomach; that her bowels were obstinately constipated, often 
not having an alvine evacuation for five or six days, and 
then passing with great pain and much difficulty only a few 
dry and hard balls of fsecal matter. In about thirty min- 
utes after such an evacuation she commences to experience 
a most intense pain in the anus, often extending into the 
pelvis, and especially to the neck of the bladder, causing 
ardor urina, and continuing for eight or ten hours, during 
which she is compelled to maintain the horizontal posture. 
No anal spasm. Mrs. D. also called my attention to an en- 
largement of the abdomen, low down on the left side, which 
had existed for three or four months, and which she said had 
been pronounced an internal tumor by her physician. Upon 
making an examination of the region indicated, I distinctly 
felt at the sigmoid flexure of the colon a nodulated tumor 
about the size of my fist, dull upon percussion, and the 
parts tender upon pressure. The left colon could be felt 
through the abdominal walls, distended with faeces. My 
opinion therefore was that the tumor was a mass of indu- 
rated fsecal matter, accumulated in the left colon; and to 
test the correctness or not of this diagnosis, as well as to pre- 
pare the patient for the exploration of the rectum, I pre- 
scribed the following stimulating cathartic : — 

Recipe, Olei Ricini, 

Terebinthinze, ana, drachmas quatuor. 

Misce. 



l66 ANAL FISSURE. 

In five hours after taking this cathartic she had a consid- 
erable evacuation of faecal matter from the bowels, but with 
no perceptible diminution, however, of the enlargement in 
the left side. I then administered the following valuable 
enema, recommended by Mr. O'Bernie in such cases, 
through an O'Bernie tube, introduced into the sigmoid flex- 
ure of the colon : — 

Recipe, Tincture Assafoetidas, drachmas duas, 

Olei Olivce, 

Magnesia Sulphatis, ana, uncias duas, 

Olei Terebinthinae, unciam, 

Infusionis Seminum Lini tepidas, octarium, 
Misce et fiat enema secundum artem. 

In fifteen minutes after the administration of this enema 
she commenced to discharge large quantities of faecal mat- 
ter, attended by much pain, vomiting, and prostration, so 
much so that anodynes, stimulants, and a bandage round 
the abdomen had to be resorted to. After a few hours, 
however, she rallied and became quite easy. On making 
an examination I found the tumor in the sigmoid flexure 
had disappeared, and upon introducing my finger nearly up 
to the second joint into the anus, which was quite relaxed, 
I distinctly felt an ulcer, situated anteriorly in the middle 
region of the anal canal. On inspection by means of the 
speculum I observed a slightly excavated ulcer, of an oval 
form and about one-fourth of an inch in diameter, with hard 
and raised edges, soft bottom, and of a grayish appearance, 
and exquisitely painful to the touch or pressure. 

The fissure was treated by the frequent application of 
the solid nitrate of silver, and the introduction of the fol- 
lowing ointment on tents or pledgets of lint : — 

Recipe, Pulveris Rhei, grana decern, 

Opii, grana quinque, 

Cerati simplicis, unciam et semissem. 

Misce et fiat unguentum. 

The bowels were relieved by aperients and enemata, and 



ANAL FISSURE. 167 

she took a tonic. She was dismissed cured in two months. 
The ulcer accounted for all her sufferings ; although not in 
the form of fissure, and unattended by anal spasm, it was 
nevertheless exquisitely irritable and painful. 

Case X. — Anal fissure in an infant ten months old. Dentition. 
Persistent diarrhoea, and procidentia ani. 

On the 10th of April, 1852, I was called to see Harriet 

T , of New Orleans, an infant at the breast, set. ten 

months. This child was suffering from dentition, and 
much debilitated by a diarrhoea, which I was informed had 
persisted for a considerable length of time, and which resulted 
in an obstinate procidentia ani. By the application of powerful 
astringents by the attending physician, Dr. P , the pro- 
lapsus rapidly disappeared; but ever since the disappear- 
ance of the protrusion, whenever the child makes efforts to 
relieve its bowels, it cries, screams, and struggles as if suffering 
terrible pain. These manifestations of suffering only last while 
the child is stooling ; immediately after, it is as quiet and as 
calm as if nothing painful had occurred. A few drops of 
blood follow each evacuation from the bowels. Dr. P. 
was of opinion that the diarrhoea was becoming dysenteric 
in character, and that it was the tenesmusofdysentery that 
caused the cries of the child during defecation. I dissented 
from this opinion, and suggested that an anal fissure might 
be the cause of these manifestations ; that by the use of 
the active astringents, the anal orifice was constantly kept 
in a firmly contracted and unyielding state, so that at some 
time when the child was making powerful efforts to extrude 
the fseces, as well as the former prolapsus, a rent in the 
mucous membrane at some point may have taken place. 
Dr. P. observed that my suggestions were plausible and 
worthy of consideration, but that he had never heard of an 
infant having an anal fissure. I proposed to him to make the 
examination, which he at once proceeded to do in the pro- 



i68 



ANAL FISSURE. 



per manner; and we soon discovered a very superficial, 
yet very distinct fissure, marked by a faint red line at the 
posterior part of the anaj orifice, on the right side. Whilst 
separating the orifice with the fingers, a little thin, bloody 
exudation took place from the posterior commissure of 
the anus. 

The child took one teaspoonful of the following prepara- 
tion four times daily : — 

Recipe, Aquas Calcis, 

Lactis recentis, ana, unciam. 
Misce. 

The local treatment consisted of a few applications to the 
fissure of the nitrate of silver in solution, by means of the 
probe, the frequent application of cacao butter, and the daily 
use of enemata of the infusion of linseed. The cure was 
completed in ten days. 

Case XI. — Anal -fissure previously diagnosed and treated by 
different physicians, severally as neuralgia of the inferior 
extremity of the rectum, internal piles, and constipation. 

Mr. L. F , a hardware merchant of New Orleans, 

La., £et. forty-three, of a lymphatico-nervous temperament, 
consulted me January 2d, 1853, ^ or wnat ne called a serious 
and painful disease at the end of the bowel. He stated 
that for two or three months past he had been suffering the 
most agonizing pain at the end of the intestine, brought on 
and aggravated by each movement of his bowels. The 
pain is of that intense burning character as if a live coal of 
fire were in the bowel, and always accompanied sooner or 
later by violent spasm of the anus. The pain sometimes 
comes on in the act of defecation, at other times it, together 
with the spasmodic contraction, comes on half an hour or one 
hour after stooling, and continues for four or five hours, 
when it suddenly subsides. During the pain the patient 
says he is compelled to remain in the horizontal posture. 



ANAL FISSURE. 169 

A short time previous to the commencement of these 
anal pains, Mr. F. had a severe bilious attack and took a 
large quantity of drastic purgative medicine, the violent 
action of which he belives gave rise to them, or at least had 
something to do in the development of the disease at the 
end of the bowel. His medical attendants treated his case 
severally as neuralgia, internal piles, and constipation of the 
bowels, by the use of quinine, iron, drastic purgatives, and 
ointments. This treatment not being at all suitable to the 
case, was, as a matter of course, anything but beneficial. 
Mr. F., from having been, previous to this attack, stout, 
hearty, and hale, had lost much flesh, looked pale and 
haggard, and was quite prostrated by his long-continued 
suffering. 

About two hours after the rectum had been completely 
cleared out by an emollient and relaxing enema, and the 
administration of a belladonna suppository, I made, without 
the use of an anesthetic, a thorough exploration of the anus 
and inferior extremity of the rectum, employing both the 
finger and the speculum; and the result of which was 
the discovery of a long and narrow superficial ulcer, with 
but slightly raised edges, situated on the mucous membrane, 
at the anterior part of the anus, on the left side, its inferior 
extremity commencing about a quarter of an inch above 
the verge of the anus. The diagnosis was now clear. 

This patient used a nourishing, but unirritating diet; 
relieved his bowels daily by relaxing and emollient enemata, 
and immediately after each movement of the bowels two or 
three tablespoonfuls of the balsamic mixture mentioned in 
Case vi. (page 161) were injected into the rectum and retained. 
By these measures, rigidly observed, and by the daily appli- 
cation to the fissure of the nitrate of silver in solution, and 
the occasional use of the bougie, the cure was complete 
in eight weeks. 

What was somewhat remarkable, this gentleman, in the 



lyO ANAL FISSURE. 

summer of 1857, was treated for and cured of a com- 
plete fistula in ano, by me in the city of New York, 
after he had been cured of his anal fissure more than four 
years. What gave rise to the anal fistula could not be sat- 
isfactorily explained. The long time that had elapsed after 
the cure of the fissure and the appearance of the fistula, 
would seem entirely to preclude the idea that the former 
was the cause of the latter. I saw Mr. F. at the St. 
Nicholas Hotel in this city last November, 1867, when he 
informed me that he continued to remain free from both 
the anal diseases, and that his health otherwise was never 
as good. 

Case XII. — Anal fissure attended by great flatulency, and accom- 
panied alternately by constipation and diarrhcea. 'The true 
nature of the case having been overlooked, it was treated 
severally as dyspepsia, anal neuralgia, and internal piles. 

Mrs. W. F , of Cincinnati, Ohio, set. twenty-four, 

bilious and nervous temperament, married five years, but 
never had children, visited and consulted me at Louisville, 
Ky., on the 16th of August, 1853. Mrs. ^- informed me 
that she suffered from indigestion, with constipation of the 
bowels, alternated with diarrhcea, and about fifteen or twenty 
minutes after each evacuation she experienced the most 
severe pain at the end of the bowel, attended by a firm 
contraction of the anal orifice. This agonizing suffering 
sometimes continues for seven or eight hours, and compels 
her to be in bed until it subsides. In this case the pain and 
the anal spasm, as well as the time of their accession, were 
in no manner influenced by the character of the stools, 
whether hard, soft, or fluid. This patient was much emaci- 
ated, highly nervous, irritable and peevish, and continually 
annoyed and pained by flatus, especially low down in the 
rectum. She had been treated for along time severally for 
dyspepsia, anal neuralgia, and haemorrhoids, with; however, 
no permanent benefit. 



ANAL FISSURE. 171 

Upon an examination of the anus, a single condyloma, 
about the size of a small pea, was observed at the posterior 
verge of the anus, on the left side, and concealed by this 
excrescence was the inferior extremity of a fissure, which, 
when the borders of the anal orifice were drawn aside, was 
plainly seen, and found to be a superficial ulcer, extending 
up the canal half an inch. This lesion had a smooth, bright- 
red surface, and slightly raised edges. On introducing the 
finger, which caused severe suffering, a peculiar rough sen- 
sation was imparted to the touch. 

For the flatulence, and to calm the irritability of the 
stomach and bowels, one of the following pills was taken 
every three or four hours : — 

Recipe, Extracti Hyoscyami, scrupulum, 

Pulveris Ipecacuanhae, grana decern. 
Fiat massa, in pilulas viginti dividendi. 

Strict diet was enjoined, and the bowels were relieved 
almost entirely by emollient enemata. The application to 
the fissure daily of the nitrate of silver in solution, and the 
occasional introduction of the bougie to dilate the anal ori- 
fice and canal, effected a radical cure of this case in two 
months. The excrescence diminished in size as the fissure 
cicatrized, and gradually disappeared. 

Case XIII. — Anal fissure complicated with hemorrhoids. In this 
case the fissure, having been entirely overlooked by the previous . 
medical attendants, was diagnosed and treated by them as 
irritable piles. 

Mr. W. H , a most estimable gentleman, and citi- 
zen of Chambersburg, Pa., set. sixty-two, of a nervous tem- 
perament, came under my care on the 14th of December, 
1854. Previous to visiting me at New York, Mr. H. 
corresponded with me in relation to his condition. The 
following is an extract from his first letter : — 



1/2 ANAL FISSURE. 

" Chambersburg, Pa., November 23d, 1854. 

W. BODENHAMER, M.D. '. 

Dear Sir : — I have been afflicted 
for the last three months with what my physician calls the 
piles; indeed I have been troubled with them, more or less, 
for the past ten years, but at no period for more than a few 
days at a time. For the last three months, however, I have 
been rendered perfectly miserable. My bowels are regular, 
and my passages quite natural; immediately upon rising in 
the morning I have a passage, regular every day, but im- 
mediately after commences a burning pain, amounting to a 
torture, continuing for about eight hours, when it subsides 
like a fire going out. I then have partial rest till next morn- 
ing, when the pain again commences in the same manner 
after stooling, so that I am quite prostrated, and am now 
writing this in bed, unable to be up. The pain I cannot 
describe ; it is peculiar to itself, and keeps me in bed more 
than half the time. Please answer this communication at 
once, and say what you can do for me, and what it will be 
necessary for me to do myself — if I must come to New 
York, how long it would require me to remain there — if so, 
where had I best stay in the city, and any other information 
it may be necessary for me to know. I am fearful that I 
could not at present bear the journey," 

I immediately replied to the above, and informed this 
gentleman that he no doubt had piles, but in addition to that 
disease he also had an anal fissure, the nature of which I de- 
scribed to him, and also gave him plain instructions how he 
or his medical attendant could without fail detect it, etc. 

In a subsequent letter, dated November 28th, 1854, he 
says : — " You have no doubt taken the correct view of my 
case. I immediately put your valuable suggestions into 
practice, and although attended with considerable pain, the 
result afforded great satisfaction, as demonstrating beyond all 



ANAL FISSURE. 



»73 



doubt the true character of my disease. Upon introducing 
the finger about half an inch, a hard point could be dis- 
tinctly felt, which was exceedingly sensitive to the touch. 
The severe pain >I suffered after each stool was supposed by 
us to have been caused by the lower sphincter (as I believe 
it is called) grasping the partially protruded piles, and 
pressing upon them for hours afterwards. Some, however, 
said it was neuralgia connected with the irritable piles. I 
have fully made up my mind to place myself under your 
care, and if I am able to travel, I will leave here about this 
day week." 

On the arrival of this gentleman I made a careful exam- 
ination of the affected parts, and discovered a fissure, with 
slightly raised and hard edges, situated between two hemor- 
rhoidal tumors, and commencing immediately within the 
anal orifice, and extending up the canal nearly one inch, 
with a small condyloma externally forming its base. I also 
discovered four distinct and regularly organized hsemor- 
rhoidal tumors, neither of which, however, was very large. 
The diagnosis in this case was now quite clear, and the 
indications equally so. 

This patient's bowels were regulated by diet and emol- 
lient enemata; the fissure was daily touched with the strong 
solution of the nitrate of silver, and when nearly cicatrized 
I began to remove the hemorrhoidal tumors by ligature, 
one by one, until they were all removed. I then removed 
the condyloma with the knife. This gentleman was dis- 
missed cured on the 19th of January, 18^5, having been 
thirty-six days under treatment. 

Case XIV. Anal fissure complicated with hemorrhoids and with 

spermatorrhoea. 

Mr. J. B. D , a notary public of New Orleans, La., 

set. twenty-eight, of a nervous temperament, applied to me 
for medical and surgical advice on the nth of April, 1855. 



J 74 



ANAL FISSURE. 



He complained of indigestion, constipation, and of a severe 
burning pain immediately after evacuating his bowels, 
attended by a spasmodic contraction of the anal orifice, 
which, together with the pain, would continue for several 
hours with intense vehemence. He also complained of 
having frequent seminal discharges, and a general weakness 
of the genital organs. He attributed this entirely to the 
pain and anal spasm, as he never had anything of the kind 
before, and never had abused the venereal pleasures. He 
informed me that he had been suffering more or less from 
these several complaints for eight months, and that he had 
been treated severally for anal neuralgia, haemorrhoids, and 
an affection of the prostate gland — the whole treatment, how- 
ever, affording but partial relief. 

Examination revealed a highly sensitive but superficial 
fissure, half an inch long, situated on the anterior part of the 
anus, commencing immediately within the anal orifice. 
Two internal hemorrhoidal tumors were also discovered. 
There was no disease of the prostate gland present, further 
than sympathetic irritation. The spermatorrhoea was doubt- 
less the result of the fissure. 

In this case the bowels were made easy by proper enemata; 
daily applications were made to the fissure of the solution 
of the nitrate of silver ; the bougie was frequently used for 
the contraction ; the hemorrhoidal tumors were removed 
by the ligature, and the cure was speedily effected. 

Case XV. — Anal fissure the result of the application of nitric 
acid to the mucous membrane of the anal canal. 

Mr. C. A. B -, of No. 16 West 23d Street, New 

York, set. forty-three, of a highly irritable constitution, con- 
sulted me on the 21st of November, 1855. Mr. B. was suf- 
fering severely from constipation of the bowels and from 
haemorrhoids, complicated with a prolapsus recti. 

On one occasion whilst I was treating this patient, after 



ANAL FISSURE. 1 J$ 

having freely applied the nitric acid to the protruded mucous 
membrane, he, in forty-eight hours after, when sloughing had 
taken place, suffered the most agonizing pain in the anus 
after each evacuation from his bowels, accompanied with 
violent spasmodic contraction of the external sphincter ani. 
His suffering was so great that I was called to see him in 
the night. Next day, on making a minute examination, a 
small fresh ulcer, the size of a split pea, evidently caused 
by the acid, was observed in the fossa between the two 
sphincters, in the posterior part of the canal. 

The daily application of a strong solution of the nitrate 
of silver to the ulcer, together with the application at the 
same time of olive oil, soon cicatrized the lesion, and entirely 
relieved him of his suffering in six days. He had never ex- 
perienced anything of the kind before ; neither has he since. 
I might have said that his bowels, which were obstinately 
constipated, were entirely relieved by enemata composed of 
the infusion of linseed and olive oil. 

Case XVI. — Anal fissure from a rupture of the mucous mem- 
brane of the anal canal, the result of a fall upon the nates. 

On the 28th of May, 1857, Mrs - S - T , of Harlem, 

New York, set. forty, a large and fleshy woman, of a san- 
guineous temperament, consulted me for a disease of the 
anal region, from which she had suffered for about three 
months. She said that two physicians had treated her case; 
the first for internal and irritable piles, the second for anal 
neuralgia. Neither of them had afforded her any perma- 
nent relief. 

In questioning her as to the origin of her anal sufferings, 
she informed me that she believed they were connected with 
an accident which had befallen her about three months ago. 
Whilst in the act of descending a very steep and narrow 
flight of stairs, when at the top, one of her feet slipped and 
she fell violently upon the coccyx, and slid in this posi- 



Iy6 ANAL FISSURE. 

tion to the bottom of the stairs. Three or four hours after- 
wards she thought she had sustained no injury whatever; 
but on the next day, when evacuating her bowels, she dis- 
covered some clots of blood mixed with the faeces, and 
about a tablespoonful of fresh blood was passed at the same 
time, and immediately followed by a smarting and burning 
pain. From that time to this she says she suffers after each 
evacuation of the bowels the most agonizing pain, espe- 
cially when the stools are hard ; sometimes lasting from five 
to eight hours, and often attended with a firm and painful 
contraction of the anus, so that nothing whatever could be 
introduced during the spasm. 

Whilst she was under the influence of chloroform I made 
a careful examination with the speculum, and observed a 
narrow slit in the mucous lining, about an inch and a quar- 
ter long, commencing just within the margin of the anus, 
at its posterior commissure, and extending up the canal 
longitudinally. 

Frequent applications of the nitrate of silver in solution 
to the rent, a large rectal bougie introduced into the rectum 
every other day, and the bowels regulated by enemata of 
the infusion of linseed, entirely relieved her in two weeks. 

Case XVII. — Several anal fissures complicated with numerous 
condylomata, and with permanent contraction of the anus. 

On the 6th of October, 1858,1 was consulted by Mrs. 

G. W. L , of Manhattanville, New York, a married 

lady, of a nervous temperament, set. thirty-five. She stated 
that she had external piles and constipated bowels; and that 
in a short time after stooling she invariably suffered the 
most severe burning pain at the end of the bowel, continu- 
ing often for three or four hours, attended with more or less 
contraction of the anal orifice. She said that this pain and 
contraction, together with a constant exudation of a thin 
yellow matter from the highly sensitive tumors, together 



ANAL FISSURE. 1JJ 

frequently with an intolerable itching, rendered her truly 
miserable. The contraction of the anal orifice was so great 
that she could not have a hard evacuation; nothing but 
fluid faeces could pass. 

Upon making an examination of the anus, I discovered a 
large number of small anal excrescences around the verge of 
the anus, and between some of these and the radiated folds 
were seen several superficial fissures or crevices, from one- 
quarter to one-third of an inch long, extending from below 
the anal orifice up into the canal. Many of the excrescen- 
ces were ulcerated at their base, and produced a permanent 
narrowing of the anal orifice. 

This lady kept her bowels in a soluble state by proper 
regimen and by the use of enemata. The nitrate of silver, 
both in its solid and fluid form, was daily applied to the 
condylomata and to the fissures. Before making the appli- 
cations the parts each time were well washed with yellow 
soap, and afterwards well dried. Pledgets of lint saturated 
with the following lotion were also kept constantly appli- 
ed: — 

Recipe, Pulveris Sulphatis Zinci, 

Aluminis, ana, drachmas duas, 

Aquas ferventis, uncias octo. 

Misce et fiat lotio. 

The bougie, together with a relaxing ointment, was also 
frequently used to break up the hard contraction. The 
result was that in a few months the anal condylomata, the 
fissures, and the contraction were all gone, and the parts 
had become soft and pliant, and performed their functions 
naturally. 

Case XVIII. Anal fissure complicated with an intolerable 

pruritus of the anus. 

Mr. E. B , of New York, a lithographer by occu- 
pation, set. thirty-seven, of a bilious and nervous tempera- 

12 



I78 ANAL FISSURE. 

ment, consulted me on the 11th of June, 1859. ^ e stated 
that for a number of years he had been troubled with indi- 
gestion, flatulence, and constipation of the bowels, together 
with an intolerable itching of the anus, which came on at 
night after becoming warm in bed, and continued for an 
hour or two, and which nothing would seem to appease. 
He was in the habit of using Brandrettis Pills to relieve the 
constipation, and various ointments and lotions for the itch- 
ing, without any permanent benefit. For the last two 
months, however, in addition to his other ailments he suffers 
a most severe burning pain in the anus after each operation 
from the bowels, lasting three or four hours ; attended at 
first by the passage of about a teaspoonful of blood from the 
anus. Whilst the pain continues he is unable to attend to 
his occupation, being confined to his room and the recum- 
bent position. In order, however, to be able to attend his 
business, he has'.lately changed the time of defecation from 
the morning to just before retiring to bed at night; but then 
he loses several hours of rest in the early part of the night. 
After the burning pain subsides the itching commences, so 
that between the two he almost suffers martyrdom. 

By making the proper exploration of the parts, I detected 
three or four quite small and superficial fissures, both without 
and within the anal orifice. I also found the mucous mem- 
brane, as well as the muco-cutaneous tissue about the anal 
orifice, in a state of chronic inflammation, and both of them 
much thickened and indurated. The mucous membrane 
especially, for more than an inch above the verge of the anus, 
was thickened, dry and friable. In this case I first proscribed 
Brandreth's Pills, and instead, the patient was enjoined to keep 
his bowels soluble by a proper regimen and the daily use of 
emollient enemata. I daily painted the whole diseased sur- 
face, both within and without the anus, with the solution of 
the nitrate of silver. The following ointment was also applied 
to the same parts twice daily : — 



ANAL FISSURE. Iy9 

Recipe, Hydrargyri Bichloridi, grana duo, 
Terebinthina; Venetian, drachmam, 
Axungie, unciam. 

Fiat unguentum. 

Before each application the patient bathed the external 
parts well with the yellow soap and water. 

By persistently pursuing this treatment for six weeks, 
the patient was entirely relieved of the fissure, the pruritus, 
and the constipation. 

Case XIX. Anal fissure in an infant suffering from aphtha. 

On the 20th of August, 1859, I was called to see Anna 

J. P , of New York, set. thirteen months, a remark- . 

ably fine, healthy looking child. The mother informed me 
that the child for some time had had the thrush badly, which 
was entirely confined to its mouth until lately, when it, or 
something like it, appeared on its fundament, which she said 
was now quite red, raw, and sore ; and that whenever the 
child evacuated its bowels, it seemed, from its sharp cries 
and the agitation of its body, to suffer the greatest agony. 
A few drops of blood follow each movement of the bowels. 
On making the examination, I found the anus firmly con- 
tracted, and otherwise in the condition the mother had descri- 
bed it. I also discovered two very superficial fissures or cre- 
vices on the left side of the anus, concealed between the deli- 
cate folds, commencing about three lines below the verge and 
extending up into the anus above the verge about two lines. 

The child was ordered a teaspoonful each of aquae calcis 
and fresh milk mixed, three or four times daily, and the 
following collutory was applied to the mouth with a mop 
or brush several times daily : — 

Recipe, Boratis Sodae, drachmam, 

Mellis despumati, unciam, 

Aquae Rosarum, uncias quatuor. 
Misce et fiat gargarysma. 



i8o 



ANAL FISSURE. 



The fissures, and the whole inflamed and raw surface 
about the anus, were touched every other day with the 
solution of the nitrate of silver. The parts were frequently 
washed with soap and water, or bathed with the decoction 
of marshmallows. Fresh lard on lint was constantly kept 
applied. 

By this treatment the child was entirely cured in ten days. 

Case XX. Anal fissure complicated with hemorrhoids and an 
affection of the prostate gland. 

At the request of Mr. R. S. H , of Alleghany 

City, Pa., I visited him at his residence on the 6th of May, 
i860. He informed me that for several months he had 
been suffering the most agonizing pain after each movement 
of his bowels, attended by violent contractions of the anus. 
He described the pain as being of an intense burning and 
lancinating character ; that it always commenced from ten 
to thirty minutes after stooling, and continued from eight 
to ten, and often to twelve hours without intermission. The 
pain sometimes extended to the neck of the bladder, 
and caused more or less retention of urine. What was 
more remarkable in Mr. H.'s case, he could not lie down 
during the pain without greatly aggravating it, and, even 
in the absence of the pain, the horizontal position would at 
once reproduce it ; consequently he could only sleep whilst 
sitting on a hard-bottomed chair. During the pain he was 
alternately sitting on a chair, or walking about the room in 
the greatest agony. He told me he had not slept in a bed 
for a number of weeks, as the horizontal posture was most 
certain to bring on a paroxysm of pain ; indeed, coughing, 
sneezing, urinating, or any sudden or violent movement 
would cause a recurrence of the same. His bowels were 
obstinately constipated, but his appetite, his digestion, and 
his health otherwise were good. He was much emaciated 
as. well as prostrated, and had that peculiar sharp expression 



ANAL FISSURE. l8l 

indicative of long-continued suffering. Mr. H. is fifty 
years of age. 

In a short time after the rectum had been completely 
emptied by a relaxing enema, I proceeded to make the 
examination. The first thing that attracted my attention 
externally was the singular appearance of the anus itself, 
which was so retracted or drawn up that it was almost 
out of sight; the next was a condyloma, about the 
size of a filbert, on the left side of the anus posteriorly. I 
also detected a small internal pile tumor on the same side 
anteriorly. Upon examining the interior of the canal with 
the finger as well as with the speculum, I detected an ulcer, 
two-thirds of an inch long and a quarter of an inch wide, 
just above the condyloma. Its edges were considerably 
raised and indurated, and the bottom soft and of a grayish 
appearance, and exquisitely painful to the touch. There 
was also discovered a considerable chronic engorgement or 
enlargement of the third or middle lobe of the prostate 
gland, which was very tender upon pressure. 

Under these circumstances, I advised Mr. H. to visit me 
at New York at once, if possible, and after recommending 
some palliative measures to be observed by him in the 
mean time, I left. 

On the 12th of May, i860, just six days after my visit 
to him, Mr. H. came to New York, when I at once com- 
menced the radical treatment of his case. His bowels were 
regulated by diet and by emollient enemata. Every morn- 
ing, immediately after the rectum was emptied by the enema, 
twotablespoonfuls of the balsamic mixture mentioned in Case 
vi. (page 161) were injected into the bowel, and retained. 
The fissure was at first touched every other day with the solid 
nitrate of silver ; occasionally, however, the acid nitrate of 
mercury was applied instead. After pursuing this treatment 
for about twelve days, Mr. H. could sleep in the horizontal 
posture, which was the first indication he experienced of a 



l82 ANAL FISSURE. 

most decided improvement. After this the nitrate of silver 
was daily applied, in the form of solution, to the fissure, and 
the frequent introduction of the bougie was adopted to 
overcome the contraction, which still remained very trouble- 
some and annoying, as it interfered greatly with defecation. 
In the mean time the condyloma and the hemorrhoidal 
tumor were removed by the ligature. Mr. H. continued 
to improve gradually until the 7th of August, when I dis- 
missed him cured. For three or four months after he left, 
he was occasionally troubled with the contraction and slight 
twinges of pain, which, however, he always relieved himself 
of by the use of the bougie. 

This gentleman was told by several surgeons, both before 
and after I commenced treating his case, that he never 
would be cured of his fissure unless the anal sphincters 
were divided according to the operation of M. Boyer. I 
had the pleasure of seeing Mr. H. in this city last Decem- 
ber, 1867, when he informed me that he still remained 
entirely free from his anal fissure and contraction, now more 
than seven years since he was cured. 

Case XXI. — Anal fissure complicated with hemorrhoidal tumors, 
the fissure situated between two of them. 

Mr. G. A. B , a glass manufacturer of Pittsburg, 

Pa., set. forty, of a sanguine and nervous temperament, con- 
sulted me on the 11th of December, 1861, for what he said 
his physician called irritable and painful piles. He informed 
me that he suffered the most intense pain after each move- 
ment of the bowels, attended by a rigid spasmodic contrac- 
tion of the anus. In stooling, a large protrusion would 
take place on the left side of the anus, which he was always 
compelled, although attended with severe pain, to replace 
as soon as possible or suffer the consequence — a prolonged 
agony. 

Gn making the examination I discovered two large 



ANAL FISSURE. 183 

hemorrhoidal tumors on the left side of the anus, and be- 
tween them a fissure nearly an inch long. 

The bowels were relieved by aperients and emollient ene- 
mata, the fissure was daily touched with the nitrate of silver 
in solution, and the tumors were removed by the ligature. 
A complete cure was effected in four weeks, the patient 
at no time during the treatment being compelled to remain 
in his room or his bed for a moment on account of it. 

Case XXII. — Anal fissure caused by chronic irritation of the mu- 
cous membrane and muco-cutaneous coat of the anus. Error 
in diagnosis and failure to afford relief by previous treatment. 

The Rev. Dr. P , of Pittsburg, Pa., consulted me 

January 31st, 1862, for a very painful affection of the anus, 
from which he had been suffering severely for several months, 
and which almost completely disqualified him from attending 
to his clerical duties as pastor of a large congregation, as well 
as those of professor in a theological college. Although 
two or three physicians had in the mean time examined and 
treated his case, they afforded him no permanent relief, in- 
asmuch as they failed to detect the real disease, and conse- 
quently failed to establish the true diagnosis of the case. 
As well as I now recollect, the case was treated as neuralgia 
of the anus or inferior extremity of the rectum. 

The Doctor informed me that he was much troubled with 
indigestion and constipation of the bowels, and that for the 
last two or three months, in a few minutes after each fsecal 
dejection, he experienced the most severe and excruciating 
pain in the anus and anal region, of a sharp and burning 
character, accompanied often with a rigid contraction of the 
anal orifice. These sufferings would continue for several 
hours, often confining him, during their continuance, to his 
room and his couch, when they would gradually or suddenly 
subside, to be again renewed after the next fsecal evacuation. 

After having heard him describe his sufferings, I at once 



184 ANAL FISSURE. 

informed him that he had an anal fissure, and that I would 
demonstrate it ocularly. I requested the Doctor to empty 
the rectum thoroughly on the following morning by an ene- 
ma composed of the infusion of linseed and castor oil, and 
that I would call at his residence afterwards and make a 
minute physical exploration of the rectum and anus. 

The rectum having been cleared out, I carefully intro- 
duced my small bivalve speculum into the anus and anal 
canal, and gradually expanded the blades to their full extent, 
when I at once detected, in the posterior portion of the anus, 
a long narrow superficial ulcer, of a bright-red color, com- 
mencing just within the anal orifice, and extending up the 
canal about two-thirds of an inch. The inferior extremity 
of the fissure terminated in a small condyloma at the verge 
of the anus, which, together with the longitudinal folds of 
the canal, completely concealed it, until it Was brought into 
view by the folds being made tense by the expansion of the 
blades of the speculum. I also observed that there was 
considerable chronic inflammation and thickening of the 
mucous membrane and muco-cutaneous coat of the anus, 
which was doubtless the cause of the fissure. No anaesthet- 
ic was employed in making this examination. The diag- 
nosis of this case was now quite clear. 

The treatment consisted in the dailv exoneration of the 
bowels by enemata of the infusion of linseed; the daily 
application to the fissure and inflamed surface of the nitrate 
of silver in solution. The patient took a mild tonic, ob- 
served an unirritating diet, and daily took moderate exer- 
cise in the open air. 

By this treatment the cure was completed in four weeks. 

Case XXIII. — Anal fissure in a nursing mother who was suf- 
fering severely from aphtha. 

Mrs. F , of W , N. Y., mother of two children 



ANAL FISSURE. 185 

and nursing the last, applied to me on the 2d of April, 1862. 
She complained of indigestion, constipation of the bowels, 
acidity of the stomach, flatulence, and canker sores of the 
gums and inside of the lips and cheeks, with a constant and 
copious flow of saliva. She says she has piles, and loses a 
great deal of blood at each evacuation of the bowels, so much 
so that she is quite anaemic; she also says that each time 
the bowels are moved she suffers the most severe burning 
pain at the anus, extending up the sacrum to the loins, 
frequently accompanied by anal spasm, and lasting from one 
to five hours. Paroxysms of these pains are frequently 
brought on by the passage of flatus from the anus, which is 
her constant dread and torment; coughing, sneezing, urina- 
ting, and singing loud, also induce or aggravate the pain. 

I at once intimated to her that she had anal fissures or 
ulcers, similar in character to those of her mouth, which 
upon examination proved to be true. 

I applied the strong solution of the nitrate of silver freely, 
once daily, to the sores of the mouth, as well as to the fis- 
sures and sores of the anus. She took regularly the bismuth 
powder mentioned in another part of this work (page 117) ; 
lived on plain and simple diet, and regulated her bowels by 
mild aperients and emollient enemata; and in the course 
of a month she was entirely cured. 

The same patient consulted me again in the fall of 1865 
for the same affection — in a worse form, however. She was 
again nursing as before. Leaving in a short time, she was 
only partially relieved by the same treatment. I have not 
heard from her since, and do not know the result of her case. 

Case XXIV. — Anal fissure complicated with hemorrhoids , and 

with an anal Jls tula. 

At the request of His Excellency , Governor of 

, I visited him professionally at his residence at 

on the 17th of May, 1862. I found the Governor much 



1 86 ANAL FISSURE. 

prostrated, quite emaciated, and highly nervous and excita- 
ble, suffering from a complication of diseases, any one of 
which would have been quite sufficient, of itself, to have 
prostrated any person, not of an extraordinarily strong con- 
stitution. I also observed that in his official capacity as 
Governor, he was overtasking his brain by attempting to do 
the mental work of half a dozen men, it being just then in 
the midst of the terrible civil war which was desolating our 
country. 

The Governor informed me that he had suffered more or 
less from piles for a number of years, but that from the labors 
and fatigues of the exciting political canvass in which he 
was engaged during the summer and fall of ] 860, they had 
become greatly aggravated. Ever since then they appear 
to have gradually changed their character, so that now, after 
each movement of the bowels, the tumors are returned with 
much greater difficulty and pain, and in a short time after 
they are returned, he suffers the most intolerable acute and 
burning pain in the anus, continuing for five or six hours 
without intermission, and frequently attended by paroxysms 
of violent anal contraction. There is constantly more or 
less discharge from the anus of mucus and matter, some- 
times mixed with blood. 

After the rectum had been thoroughly emptied by an 
enema of the infusion of linseed and castor oil, and before 
the protruded parts were returned, I made a careful ex- 
amination, and found four large hemorrhoidal tumors pro- 
truding, and between two of these, at the posterior part of 
the anus, I detected a fissure the eighth of an inch wide, 
commencing at the verge of the anus, and extending up 
the canal nearly an inch. The surface of the ulcer was 
florid and its edges were raised and hard. I also discovered 
the external orifice of a small anal fistula, situated on the 
left side of the anus posteriorly. Upon probing the fistula, 
I found it communicated with the bowel. 



ANAL FISSURE. 1 87 

In this instance the fissure was doubtless the result of a 
laceration of the mucous membrane produced at some time 
during the forcible expulsion of indurated faeces, and the 
fistula, the result of the continued and combined irritation 
kept up in the parts by both the haemorrhoids and the fissure. 

The anal fissure was cured in about three or four weeks 
by my son, Dr. W. H. Bodenhamer, who remained with the 
Governor in his house. The ulcer was daily touched with 
the nitrate of silver in some form or other, and the bowels 
were almost entirely relieved by emollient enemata. 

Subsequently to the cicatrization of the fissure, the Gov- 
ernor visited me at New York, where I cured the anal fistula 
by the use of the ligature, and removed the hemorrhoidal 
tumors by the use of the same means. I have just had the 
pleasure of a call (this 17th day of June, 1868), from my 
friend Ex-Governor , who I am happy to say is en- 
tirely well. He says that he remains entirely free from all 
his anal affections; that the cure is complete and radical, 
being now six years since I dismissed him well. 

Case XXV. — Fissures and aphthous abrasions and ulcerations 
of the anus, in connection with nurses' sore mouth. 

On the 16th of July, 1863, I was called to see Mrs. G. 

R , of New York, set. thirty-eight, mother of several 

children and nursing the last one. I found her suffering from 
indigestion, frequent sour eructations from the stomach, 
abrasions of the lips, fissures of the tongue as well as of 
the anus, and general relaxation. 

On making an anal examination, I discovered a number 
of superficial fissures and ulcers, both immediately without 
and within the anal orifice, which were of a bright-red color 
and highly sensitive to the touch ; and from which she suf- 
fered the most intense burning pain whenever she evacuated 
her bowels. The pain would sometimes continue three or 
four hours, and often attended by firm contraction of the 



i88 



ANAL FISSURE. 



anal sphincters. She informed me that she suffered severely 
from haemorrhoids, but only during pregnancy; and that 
she always had a sore mouth whilst nursing, but never before 
suffered from pain at the anus, neither at the time of, nor 
after evacuating her bowels. 

The treatment of this case was in every respect similar to 
that of Case xxiii. ; and a complete cure w T as effected in four 
weeks. 

Case XXVI. — Anal fissure following the ligation and sloughing 

of a hemorrhoidal tumor. 

Mr. H. McC , of Harrisburg, Pa, set. thirty-five, of a 

bilious temperament, consulted me in May, 1864, for a 
haemorrhoidal affection. On the sixth or seventh day after 
ligating the last tumor, a quite large one, it became detached 
during the severe straining efforts at evacuating hard feces, 
causing at the time a little haemorrhage and considerable 
burning pain. On the next and subsequent evacuations 
the burning pain was extreme, and attended with spasmodic 
contraction of the anus, thereby greatly increasing the pain 
and making it almost unbearable. Upon examination, I 
discovered on the left side of the anus, about four lines 
above its margin, a small oval and angry-looking ulcer at 
the spot where a portion of slough had become detached. 

A few applications of the nitrate of silver to the ulcer, 
and dilatation of the sphincters of the anus, relieved him 
entirely in three days. 

Case XXVII. — Anal fissure in a patient with albuminous urine, 
whose general health was much impaired. 

E. L , of New York, an Irish servant girl, set. twen- 
ty-one, very pale, thin, and much impaired in health, con- 
sulted me on the 20th of May, 1 865. She is very nervous, 
has a morbid appetite, obstinate constipation of the bowels, 
constant distressing flatulence, and irregular and scanty cata- 



ANAL FISSURE. 189 

menia. About half an hour after each movement of the 
bowels she says she suffers the most dreadful pains at the 
fundament, which continue without intermission for several 
hours, and then subside, to be renewed on the next faecal 
dejection. She also loses a large amount of blood at each 
alvine evacuation, but says she has never discovered any 
tumors. 

An examination disclosed two anal fissures — one in front, 
and one on the right side of the anal orifice — both extending 
some considerable distance up the canal. From her appear- 
ance and general ill health I was induced to examine the 
urine, and found it albuminous. The condition of this poor 
girl was anything but flattering, yet in the course of four 
months her general health was restored ; and long before she 
had been entirely relieved of her fissures, without either cut- 
ting or forcible dilatation, for no prudent or educated sur- 
geon would, in her condition, have performed either opera- 
tion. 

The bowels were regulated by diet, mild aperients, and 
enemata, and she took as a tonic twenty drops of the follow- 
ing solution, three times daily, in an infusion of quassia : — 

Recipe, Citratis Ferri, drachmas duas, 

Sulphatis Quiniae, semi drachmam, 

Acidi Citrici, grana viginti, 

Aquae destillatae, unciam. 
Fiat solutio. 

Her diet was nourishing, consisting of roast beef, beef- 
steak, mutton chops, &c. The fissures were treated by 
the daily application of the solution of nitrate of silver, 
and were entirely cicatrized at the end of four weeks. The 
hsemorrhage proceeded from the anterior fissure, and gradu- 
ally ceased as the healing progressed. This patient improv- 
ed rapidly, she gained flesh and strength, and her face lost 
its pallor, by arresting the hsemorrhage, by the use of the 
nourishing diet and the citrate of iron. 



190 ANAL FISSURE. 

When from any cause the operation of incising the 
mucous membrane, of dividing the anal sphincters, or of 
forcible dilatation, is contra-indicated, the method of topical 
applications, as recommended in this work, especially 
becomes invaluable. 

Case XXVIII. — Anal fissure the result of obstinate constipation 
of the bowels, and the passage of scybalous faces. 

Mrs. B , of Flushing, N. Y., set. thirty-three, mother 

of one child eight years old, of a bilious and nervous tempera- 
ment, consulted me on the 10th of September, 1866, by the 
advice of my excellent and good friend Dr. J. F. Gray, 
to whom I am greatly indebted for many favors of this 
kind. Mrs. B. informed me that she has suffered from 
obstinate costiveness from her earliest recollection, otherwise 
her health was good, until, within the last year or six months, 
she commenced to suffer the most agonizing pain in the 
anal region a short time after each evacuation of the bowels, 
attended by a firm and violent contraction of the anus. 
The pain and the contraction on some days would continue 
as long as six or ten hours, confining her during the time 
to her bed or couch. It was supposed she was suffering 
from haemorrhoids. 

On making an examination, I observed a condyloma 
about the size of a large pea at the posterior verge of the 
anus on the left side, and on drawing down the borders of 
the anal orifice, I plainly saw the inferior extremity of a 
superficial fissure concealed by the condyloma. Upon 
using the finger and speculum, which was attended with 
severe pain, no anaesthetic having been employed, I found 
the fissure extending up the canal about three-fourths of an 
inch, having a bright-red and raw surface, and slightly 
raised edges. 

The treatment of this case consisted in the regulation of 
the bowels by a mild aperient, and by the daily use of an 



ANAL FISSURE. I9I 

emollient enema ; by the frequent application to the fissure 
of the strong solution of the nitrate of silver, and by the 
occasional use of the bougie. By this course a rapid im- 
provement soon took place ; but on several occasions, when 
it was supposed the fissure was cicatrized and entirely well, 
an evacuation of hard fsecal matter would open the fissure 
and reproduce the pains ; so that the treatment was unusu- 
ally protracted, and causing great discouragement. The 
regulation of the bowels, and a few applications to the fis- 
sure, however, always promptly relieved the pain. It is now 
nearly a year since any pain has been experienced, although 
on several occasions hard evacuations have taken place, so 
that Mrs. B. considers she is permanently cured. 

» 
Case XXIX. — Irritable ulcer situated in the fossa between the 
external and internal sphincter of the anus. 

Mr. Van N , of New York, a student of Bellevue 

Medical College, set. thirty-one, of an atrabilious tempera- 
ment, consulted me on the 26th of November, 1866, for 
what he believed either neuralgia of the inferior extremity 
of the rectum, or anal fissure. Mr. Van N.'s general health 
is good, but he suffers from indigestion and constipation of 
the bowels. A short time after each evacuation of the 
bowels, he experiences the most intense burning pain some 
little distance above the anal orifice, attended occasionally 
by a slight spasm of the anus, and by a small purulent dis- 
charge. This pain on some days, especially when he has 
very hard stools, will continue for five or six hours after 
having such an alvine dejection. 

On making an inspection of the parts, I discovered a por- 
tion of the verge of the anus, on the left side posteriorly, 
to be red, swollen, and everted, and on introducing the right 
index finger into the anus a little above the second joint, I 
could distinctly feel a large excavated and highly sensitive 
ulcer, with hardened edges and soft bottom, situated on the 



1'9 2 ANAL FISSURE. 

posterior portion of the canal, in the fossa between the two 
anal sphincters. By the use of my small speculum, I discover- 
ed the ulcer to be about the size of an American silver ten- 
cent piece, of a grayish appearance, with elevated edges and 
soft and spongy bottom, answering the exact description of 
certain ulcers in this locality given by Mr. Colles, and men- 
tioned in another part of this work. 

The treatment in this case consisted in moving the bowels 
by emollient enemata, the daily application to the ulcer, 
made visible by the speculum, of a saturated solution of the 
nitrate of silver. By this treatment a cure was effected in 
three weeks. The peculiar laxity and lip-like protrusion of 
the external margin of the anus in this case, gradually dis- 
appeared as the ulcej above it became healed. 



Section II. — Bibliography. 

A. 

^Etius. Medici Graeci contracts ex veteribus Medicinse 
Tetrabiblos, hoc est Ouaternio. Tetr. IV. Serm. 2. cap. 3. 

Basil, 1542. Folio. 
Albucasis. Chirurgi Methodus Medendi. Lib. II. cap. 81. 

p. 633. Channing's Edition. 
Alison ( W. P.). Cyclopaedia of Anatomy and Physiology. 

By R. B. Todd, M.D. Vol. 1. Art. Contractility, p. 719. 

London, 1836. 
Ashton (T. J.). Diseases, Injuries and Malformations of the 

Rectum and Anus. Third Edition, p. 44. London, i860. 

B. 

Baillie (Matthew). Medical Transactions of the College 
of Physicians of London. Vol. V. p. 136. London, 
1815. ' 



ANAL FISSURE. I93 

Basedow. Ueber die Strictura Ani Spastica. In Graffe 
and Walther's Journal der Chirurgie. Band VII. s. 125. 
Berlin, 1826. 

Beclard (P. A.). Archives Generates de Medecine. Tome 
VII. pp. 139, 310. Paris, 1825. 

Begin (L. J.). Observations relatives aux Fissures de l'Anus. 
In Recueil de Memoires de Medecins Militaires. Paris, 
1826. 

Bellingeri (C. F. J.). Experimenta Physiologica in Me- 
dullam Spinalem. Lecta die 13 Junii, 1824. From 
Memorie della Reale Accademia della Scienze di Torino 
XXX. Turin, 1826. Analyzed in the Journal des 
Progres des Sciences. Tome I. p. 125. Paris, 1827. 

Black (James). A Manual on the Bowels, p. 213. Lon- 
don, 1840. 

Blackett (Powell). London Medical Repository. Vol. 
VII. p. 377. May, 1817. 

Blandin (P. F.). Dictionnaire de Medecine et de Chirurgie 
Pratiques. Art. Fissure. Tome VIII. p. 1 J5. Paris, 1 832. 

Bouchut (E.). A Practical Treatise on the Diseases of 
Children. Bird's English version, p. 528. London, 

1855- 

Boyer (M. le Baron Philippe). Traite des Maladies Chi- 
rurgicales. Tome VI. p. 605. Cinquieme edition. Paris, 
1849. Also, Journal Complementaire du Dictionnaire 
des Sciences Medicales. Tome II. p. 24. Paris, 1818. 

Bretonneau (P.). Gazette Medicale. Tome VIII. No. 
36, p. 59. Paris, 1840. 

Brodie (Sir Benjamin C). Clinical Lectures on Surgery. 
Lect. XXXVI. p. 322. Philadelphia, 1846. 

Brown ( J. Baker). London Lancet, July 14th, i860, 

P-3 1 - 

Bushe (George). A Treatise on the Malformations, Injuries, 

and Diseases of the Rectum and Anus, p. 99. New York, 

] 837- 

*3 



194 ANAL FISSURE. 

c. 

Calvert (George). A Practical Treatise on Haemorrhoids 
and other Important Diseases of the Rectum and Anus, 
p. 211. London, 1824. 

Chelius (Maximilian Joseph). Handbuch der Chirurgie. 
Band II. s. 34. Heidelberg und Leipzig, 1827. 

Coates (Reynell). American Cyclopaedia of Practical 
Medicine and Surgery. Vol. II. Art. Anus, p. 118. 
Philadelphia, 1841. 

Colles (Abraham). Lectures on the Theory and Practice 
of Surgery. Edited by Mr. S. M. McCoy, p. 279. Phila- 
delphia, 1845. Also, Dublin Hospital Reports, Vol. V. 
p. 155. Dublin, 1830. 

Copeland (Thomas). Observations on the Principal Diseases 
of the Rectum and Anus. Second edition, pp. 46, 136. 
London, 1814. 

Curling (T. B.). Observations on the Diseases of the Rec- 
tum. Third edition, p. 5. London, 1863. 

D. 

Delaporte. Observations sur l'heureux emploi de la 

belladone dans un cas de fissure et de constriction 

spasmodique de l'anus. In Journal General de Medecine. 

Tome CX. p. 329. Paris, 1830. 
Delauney (J. Aug.). Essai sur la Fissure ou Gercure a 

PAnus. These de Paris, Annee 1824. No. 215. 
Delpech (J.). Precis Elementaire des Maladies reputees 

Chirurgicales. Tome I. p. 598. Paris, 1816. 
De Montegre (A. J.). Des Hemorroi'des, ou traite analy- 

tique de toutes les Affections Hemorroi'dales. Nouvelle 

edition, publiee par sa Veuve, p. 51. Paris, 1819. 
Descude. Mott's Velpeau; Vol. III. p. 1112. New 

York, 1847. 
Dionis (Pierre). Cours d'Operations de Chirurgie demon- 

strees au Jardin du Rio. Huitieme edition. Par De La 

Faye. Tome I. p. 397. Paris, 1782. 



ANAL FISSURE. 1Q5 

Dupuytren (M. le Baron). Legons Orales de Clinique 

Chirurgicale. Tome III. Art. 10, De la Fissure a l'Anus, 

p. 150. Bruxelles, 1836. 
Duroutge. Dissertation sur la Constriction Spasmodique 

du Sphincter de l'Anus, accompagnee de Fissure. 

These de Strasbourg. Annee 1829. 

F. 

Fergusson (William). A System of Practical Surgery, p. 
550. Philadelphia, 1853. 

G. 

Gaitskell (William). London Medical Repository, Vol. 
IV. p. 51. July, 1815. 

Gendrin (A. N.). Traitement des Fissures de l'Anus. In 
Transactions Medicales. Tome VI. p. 24. Paris, 1831. 

Gossement. Malgaigne; Operative Surgery. English ver- 
sion, by F. Brittan, M.D. p. 429. Philadelphia, 1851. 

Gross (Samuel D.). A System of Surgery. Vol. II. p. 736. 
Philadelphia, 1859. 

Guy (De Chauliac). Magna Chirurgia. Tract IV. doct. 
2, chap. 7. Venetii, 1490. Folio. 

H. 

Harrison (Robert). Cyclopaedia of Anatomy and Physi- 
ology. By R. B. Todd, M.D. Vol. I. Art. Anus, p. 185. 
London, 1835. 

Hay ward (George). Report of the Surgical Cases that 
occurred in the Massachusetts General Hospital, from the 
12th of May, 1837, to the 12th of May, 1838. Boston, 

1838. 

Hervez De Chegoin (N. J.). Traitement des Fissures de 
l'Anus. In Transactions Medicales. Tome VI. p. 24. 
Paris, 1831. 



I96 ANAL FISSURE. 

Howship (John). Practical Observations on some of the 
Diseases of the Lower Intestine and Anus. Third edition, 
pp. 4, 210, 240, 245. London, 1824. 

L. 

Lab at. De la Fissure a l'Anus et de sa cure radicale 
par le moyen du Sphincterotome. In Annales de la 
Medicale Physiologic Tome XXIV. p 207. Paris, 1833. 

Laborderie (A.). Revue Medicale de Paris. Juillet, 1830. 

Lamoureux. Societe de Medecine de la Seine-Infer. 
Tome IX. p. 78. 

Lemonnier (L.). Traite de la Fistule de l'Anus, p. 160. 
Paris, 1689. 

Liston (Robert). Clinical Lecture at London University 
Hospital. In Medico-Chirurgical Review, April, 1835. 
No. XLIV. p. 490. 

Louvet-Lamarre. Constriction Spasmodique du Sphinc- 
ter de l'Anus guerie par l'emploi simultane de meches 
de charpie et de preparations de belladone. In Nouveau 
Bibliotheque Medicale. Tome II. p. 389. Paris, 
1827. 

M. 

Malgaigne (J. F.). Operative Surgery. English version, 
by F. Brittan, M.D. p. 429. Philadelphia, 1851. 

Malyn (John). Cyclopaedia of Practical Surgery. By 
W. B. Costello, M.D. Vol. I. Art. Anus, p. 341. London, 
1841. 

Marjolin (M.). Quoted by Cabanellas. These de Paris. 
No. 132. Annee 1826. 

Mayo (Herbert). Observations on Injuries and Diseases of 
the Rectum, p. 3. London, 1833. 

Merat (F. V.). Dictionnaire des Sciences Medicales. 
Tome XV. Art. Fissure. Paris, 1816. 

Miller (James). The Practice of Surgery, p. 380. Ed- 
inburgh, 1852. 



ANAL FISSURE. 1 97 

Morrison (M.). American Journal of the Medical Sciences. 

No. XLIV. p. $36. Philadelphia, August, 1838. 
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de Medecine et de Chirurgie. Tome II. p. 31. Paris 

et Lyon, 1827. 

N. 

Nacouart. Traitement des Fissures de l'Anus. In Transac- 
tions Medicates. Tome VI. p. 24. Paris, 1831. 

Nelaton (Auguste). Clinical Lectures on Surgery. From 
Notes taken by W. F. Atlee, M.D. p. 552. Philadelphia, 

1855. 

Nevermann. Ueber die Fissure des Afters, oder die Stric- 
tura Ani Spastica. In Holcher's Hannoverischen Annalen. 
Band I. s. 729. 

P. 

Pagen. Gazette Medicale. Tome VIII. No. 4, p. 59. 
Paris, 1840. 

Paillard (Alex.). Fissure a l'Anus traitee et guerie sans 
secours de l'incision ni de la cauterisation. In Revue 
Medicale de Paris. Tome I. p. 869. Annee ] 829. 

Pancoast (Joseph). Operative Surgery, p. 307. Philadel- 
phia, 1844. 

Pare (Ambrose). The Works of. English version, by 
T. Johnson. Chap. LXIII. p. 954. London, 1634. 
Folio. 

Pauli (iEginetse). Libri Septern. Greek et Latin. Lib. 
VI. cap. 80. Basilar, 1532. Folio. 

Pirrie (William). The Principles and Practice of Sur- 
gery, p. 653. Philadelphia, 1 852. 

O. 

Ouain (Richard). The Diseases of the Rectum. Second 
edition, p. 154. New York, 1855. 



I98 ANAL FISSURE. 

R. 

Recamier (J. C. A.). Revue Medicale de Paris. Janvier, 

1838. 

Richerand (A.). Archives Generales de Medecine. Tome 

VII. pp. 139, 310. Paris, 1825. 

Riverius (Lazarus). The Practice of Physic. Book X. 

chap. 11, p. 316. London, 1658, Folio. 
Roche (L. C). Nouveaux Elements de Pathologie Medico- 

Chirurgicale. Ouatrieme edition. Tome III. p. 634. 

Paris, 1844. 
Rouse (James). On Ulceration of the Lower Extremity 

of the Rectum ; its Varieties, Diagnosis, and Treatment. 

In British Medical Journal, May 12, i860. P. 356. 

If S * 

Salmon (Frederick). A Practical Essay on Stricture of the 

Rectum. Fourth edition, pp. 70, 180. London, 1833. 

Sanson (L. J.). Nouveaux Elements de Pathologie Medi- 
co-Chirurgicale. Quatrieme edition. Tome III. p. 
634. Paris, 1844. 

Scallan (J. J.). Dublin Journal of Medical Science. 
November, 1845. P* 21 7* 

Smith (Henry). Haemorrhoids and Prolapsus of the Rec- 
tum. Third edition, p. 124. London, 1862. 

Smith (Henry H.). A System of Operative Surgery. Vol. 
II. p. 330. Philadelphia, 1856. 

Syme (James). On Diseases of the Rectum. Third edi- 
tion, p. 125. Edinburgh, 1854. 

i T ' 

Thibord. Essai sur la Fissure ou Gergure a FAnus. These 

de Paris. No. 194. Annee 1828. 

Trousseau (Armand). Gazette Medicale de Paris. Tome 

VIII. No. 36. Annee 1480. Also, London Lancet, 
Vol. IV. p. 157. 1846. 



ANAL FISSURE. I99 

V. 

Van Buren (W. H.). Certain Points in the Treatment of 
Diseases of the Rectum. Read before the New York 
Academy of Medicine, December 16th, 1863. In 
American Medical Times. Vol. VIII. p. 218. New 
York, 1864. 

Velpeau (Alf. L. M.). Dictionnaire de Medecine. Deuxi* 
erne edition. Tome III. p. 300. Paris, 1833. Also, 
Mott's Velpeau, Vol. III. p. 1108. New York, 1847. 

V 1 vent. Dissertation sur la Fissure a l'Anus. These de 
Paris, No. 132. Annee 1830. 

W. 

White (W.). Observations on Strictures of the Rectum. 

Third edition, p. 10. Bath, 1820. 
Wiseman (Richard). Several Chirurgical Treatises. Book 

III. Chap. 3, p. 222. London, 1676. Folio. 



By the same Author. 

A PRACTICAL TREATISE ON THE 
AETIOLOGY, PATHOLOGY, AND TREATMENT OE THE 

Congenital Malformations of the Rectum and Anus. 

In One very handsome Octavo Volume of 368 Pages. Illustrated by Sixteen Superb 

Lithographic Plates. 

Bound in Extra Cloth, $4.00. 

William Wood & Co., 61 Walker Street, New York. 



NOTICES OF THE MEDICAL PRESS. 

" This work constitutes one of the most complete monographs with which we are 
acquainted. In it we have collected, and apparently with accuracy, no less than 
287 cases from every available source, and also a review of both the medical 
and surgical treatment in full from the earliest times, with all the improvements 
down to the present time." 

" The materials collected and introduced into the work are well digested, with full 
and particular references to their sources ; and in the relation of the various cases, 
the remarks of the original writers are given in connection with them. The volume 
is well illustrated by 16 plates, each containing several drawings. Altogether, the 
book is a complete and valuable compendium on the subject up to the time of its 
publication, and a monument of industry and patience." — British and Foreign Medico- 
chirurgical Review. 

" This is a most complete and valuable work, treating in an exhaustive style of a 
class of affections on which no complete systematic or practical treatise has hitherto 
been published.- A copious bibliographical index is given, and on the whole the 
treatise is most complete, ranging throughout almost the whole literature of the 
subject, and nearly exhausting all that is to be said on it in the present state of our 
knowledge." " The subject is one well worthy of the labor Dr. Bodenhamer 
has bestowed upon it, and worthily has he worked it out." — Dublin Journal of 
Medical Science. 

" The style of this author is concise and agreeable, and his subject interesting; 
his work will well repay perusal, although its immediate study may not be required. 
Unfortunately it belongs to that class of books which a physician, having no cases 
of the kind to treat, feels indifferent in possessing, and scarcely willing to admit as 
necessary. It shows itself forth, however, in bold relief, as one of the most impor- 
tant and useful, when he is called to operate on some unfortunate child thrown 
suddenly in his charge. Glad of the opportunity of examining its valuable pages, 
he will then agree with us on its extreme utility, and in considering that no medi- 
cal library can be called complete without it. It is a large octavo of upwards of 300 
pages, Med with beautiful lithographs ; and, besides, separate and distinct treatises 
on the different species of malformation and their treatment, containing, in elucida- 
tion of the subject, upwards of 200 cases, gathered from every reliable source, 
classified and tabulated. By these we find that of 156 on which operations have 
been performed, 87 have recovered : this is encouraging, for of 42 for which nothing 
had been done, all but 12 succumbed. Finally, 50 pages are devoted to the differ- 
ent modes of performing the operation for abdominal artificial anus, which are plain- 
ly illustrated by lithographs.''' — Canada Lancet. {Montreal.) 

" To the practitioner who desires to be prepared for every emergency, we 
commend this volume as an indispensable addition to his library." — American 
Medical Times. 

" This is a most valuable monograph on subjects on which little knowledge is to 
be derived from our surgical books. The author appears to have fully elaborated 



Notices of the Medical Press Continued. 



and exhausted the subject, having collected from all sources nearly three hundred 
cases, and illustrated the most remarkable by sixteen plates, which are well exe- 
cuted, and render the volume an attractive and useful one." — American Medical 
Gazette. 

" This is an opportune and valuable addition to the means of acquiring a know- 
ledge of the diseases of the rectum, which the excellent works of Ashton, Quain, 
Syme, Bushe, and Copeland have so clearly and fully furnished to English and Ameri- 
can readers. As a practical monograph it is not inferior to either of these, so far as 
relates to its particular department of the subject ; while it surpasses them all 
in completeness and extent of illustration, and in the facilities afforded to the student 
for the purpose of further investigation. The work is no empty compilation, since 
the author's views are clearly and precisely given upon all practical points, and 
many useful practical details are pointed out, in a manner which shows them to be 
the product of much especial thought and observation as well as practical skill and 
intelligence." — American Journal of the Medical Sciences. 

" The work before us is one that cannot fail to interest all diligent inquirers in 
the ranks of the medical profession, at the same time that it will add much to the 
reputation of one of its laborious members. Asa monograph it may be taken 
almost as a model ; while the subject is one upon which the profession were little 
enlightened, its literature being principally scattered through the published transac- 
tions of various medical societies, or appearing in isolated cases reported in various 
medical journals." 

" In conclusion, we would merely say that the volume which Dr. Bodenhamer has 
given to the profession is most creditable to himself and to the profession in this 
country ; and must be considered by far the most valuable, if not the only text-book 
on this subject." — Boston Medical and Surgical Journal. 

" "We give this work of Dr. Bodenhamers a cordial welcome to our table, both on 
account of the intrinsic value of the work itself, and our esteem and friendship for 
the author, who has labored hard, but successfully, for many years in this branch of 
medical science." 

u The work is unique, being the only complete, systematic, and practical treatise 
upon the subject ever published. It contains, in addition to his own vast experi- 
ence, the productions and contributions — to the literature of this subject — of all the 
eminent surgeons of Europe and America; — thus collecting and combining, in a 
compact and condensed form, what has heretofore been scattered over the two 
hemispheres, in brief and detached articles, memoirs, and essays, as presented 
in the transactions of medical societies ; in brief monographs ; in different periodi- 
cals. &c." 

" Dr. B. has devoted an immense amount of labor and time in the production of 
this invaluable work, for which he richly merits the thanks and the gratitude of 
the entire medical profession." — Eclectic Medical Journal. 

" Congenital vices of conformation constitute many of the most unfortunate dis- 
orders to which the human frame is liable. Some of them are incurable, either 
causing early death, or allowing life to be prolonged in suffering and deformity 
(Spina Bifida, Exstrophy of the Bladder, Deformities of the Limbs, Phocomele, (fee). 
Others are curable, but demand for their relief the highest resources of the medical 
art (Hernia, Cleft Palate, Hare Lip, Club Fool). The congenital malformations of 
the rectum and anus include representatives of both these classes. Although of not 
infrequent occurrence, they are not sufficiently numerous to permit the general 
possession of experience in their management among practitioners ; so that a practi- 
cal treatise on the subject, embodying the requisite details of diagnosis and treat- 
ment is of great value to the profession. The able work of Dr. Bodenhamer before 
us has this merit: It is concise, full, and practical; and in addition to this claim, 
possesses that of being the only complete and practical work on congenital malfor- 
mations of the rectum and anus which has ever been published in this, or in any 
other country." — Berkshire Medical Journal. 

" This able work of Dr. Bodenhamer will be welcomed by the profession, as filling 
a void which has heretofore existed, and as presenting the opinions and' reports of 
cases that have been made through journals, reports of medical societies, or pub- 
lished as monographs, and were beyond the reach of the mass of the profession." — 
Journal of Rational Medicine. 

" We cordially recommend this work to the profession." — Savannah Journal of 

" Is the most complete work of the kind that has ever been published." — Medical 
Journal of North Carolina. 






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